14 June 2018

Before HM Assistant Coroner Oliver Longstaff 
West Yorkshire Coroner’s Court 
Opened 4 June 2018 and concluded 6 June 2018 

The inquest into the death of Jordan Nathaniel Cooke, known as Nathan to his friends and family, concluded on Wednesday 6 June 2018, with the jury finding that there was an opportunity for mental health services to become involved if information had been passed on. Nathan was found hanging at his home address 16 hours after being released from custody.

Nathan, a 23 year old black man from Halifax, had a long history of self-harm and interaction with mental health services, and was diagnosed with Adult ADHD and psychosis. On 25 January 2015, he was arrested by West Yorkshire Police. At the time of the arrest Nathan was reported to be highly agitated. He was placed into a camera cell with a detention officer monitoring a live stream of the cell.

Following serious attempts of self-harm, Nathan’s risk was escalated to the highest level available. He was placed on ‘close proximity’ observations, with a police officer sat at the cell door at all times. A doctor attended to assess Nathan and established a care plan on the understanding that he would be kept in custody overnight and continually observed. However, during the inquest the doctor said he did not believe that he had been informed of Nathan’s history of self-harm nor the most recent attempts at self-harm that day prior to the assessment.

The inquest heard that Nathan became particularly upset upon hearing the bail conditions and was concerned about being able to have contact with his daughter. The interviewing officer advised the inquest that Nathan calmed down once he was told there were avenues through which he could see his daughter.

Nathan was released from the police station that evening however, his pre-release custody risk assessment was not completed until nearly an hour after Nathan’s departure from the police station. The doctor said that had he been aware of Nathan’s intended release, he may have contacted the local Mental Health Crisis team.

Nathan’s family said: The issue in this case for the family, was and has always been that the police had a statutory duty of care, and failed to adhere to their own safeguarding policies, procedures and protocols. The police had all the relevant information to correctly advise the doctor, who came to assess my son hours prior to the doctor attending the police station. I believe that the police simply chose not give the doctor the information, which would have allowed him to conduct a proper medical assessment and which would have led to other options being explored including intervention from the mental health teams.

During the course of the investigation into my son’s death it came to light that there was an individual who witnessed the “alleged” incident for which my son was arrested for, the police were aware of this which is why my son was released on bail, he died before those enquiries could be made, which I believe would have shown that he was not guilty of the offence.

My son was a twin and loving father, who idolised his daughter. She now has to grow up without a dad who loved her more than anything in this world.”

Gemma Vine, Head of Civil Liberties at Minton Morrill solicitors said: This is a tragic case where a vulnerable young man’s care fell short of what should have been provided by the Police. The inquest has highlighted failings in the provision of care provided to Nathan, including the failure to pass on vital and relevant information to the medical examiner about Nathan’s self harm risk and about Nathan’s intended release causing him to be released without the support of Mental Health services and without a full medical assessment. It is hoped that these shortcomings are addressed to prevent any future deaths from occurring.



For further information, please contact Lucy McKay or Sarah Uncles on 020 7263 1111 or [email protected] or [email protected] 

INQUEST has been working with the family of Jordan Nathaniel Cooke since his death. The family is represented by INQUEST Lawyers Group members Gemma Vine of Minton Morrill Solicitors and Nick Stanage of Doughty Street Chambers.