11 February 2021

Before HM Assistant Coroner Karin Walsh
Sunderland Coroner’s Court
19 - 21 January 2021

The inquest into the death of 19 year old Keaton Burton concluded on 21 January finding his death was a suicide with the coroner highlighting a number of issues in the care he received.

Keaton was admitted as a voluntary inpatient to the Tramwell Mental Health Unit in Gateshead, Tyne and Wear after a serious attempt to take his own life on the 12 June 2019. He was allowed to go on unescorted leave from the unit, but absconded and walked 15 miles to a family member’s home. Northumbria Police were alerted to Keaton’s whereabouts by family members and were due to return him to hospital. Before their arrival he was able to leave unnoticed. He was found dead in a local woodland in Sunderland the following day on 24 June 2019.

Keaton’s family describe him as a lovely kind person. He was very popular and had a lot of really good friends. He was always making people laugh. Anyone who knew him will have a funny story to tell about him. He had a love for cars and a passion for dance and rap music and had begun writing his own rap lyrics. He is hugely missed by his family and friends, who say his death left a hole in the hearts of everyone close to him.

Keaton had a history of mental ill health, which in the lead up to his death had deteriorated and become increasingly concerning to his family. A few months before his death, in April 2019 Keaton’s mother made contact with the Crisis team in Sunderland, part of Cumbria Northumberland Tyne and Wear NHS Foundation Trust, who only recommended taking Keaton to his GP where he was prescribed anti-depressants.

Less than two weeks before his death, on 12 June Keaton was found by police with a ligature and admitted to officers that he was planning suicide. He was taken to a police cell, where he was found in distress, butting his head, and was subsequently restrained by police. Keaton was then returned to the Crisis team and admitted as a voluntary patient to Tramwell Mental Health Unit.

Keaton remained as a voluntary patient, as the review into his care plan which was due within 72 hours of admission was cancelled and didn’t take place for 10 days, even after he had requested to leave. On the three occasions Keaton asked to leave, a doctor was called to assess him but because he agreed to stay or said he no longer wanted to leave, no further mental health assessment was carried out to determine whether he should be detained under the Mental Health Act

On 23 June, Keaton approached a support worker who claims that Keaton was advised to speak to the Head Nurse on duty who was happy for him to go out for a cigarette at 10:30pm. Keaton had been allowed short breaks to the front of the building for 10 minutes at a time, which he had utilised correctly during the day time. Staff didn’t realise Keaton had not returned until 11.15pm, when they did a head count due to a fire alarm going off at 11.05pm. Staff searched the grounds for Keaton and reported him missing to police at 11.54pm.

Keaton made the 15 mile walk to a family members’ house, arriving at 7.30am the following day. His family alerted the police and arranged that he would shower and get changed before being returned to hospital by police. Whilst he was thought to be showering in the family home, Keaton left the house. He was reported missing and found dead the following day on 24 June 2019 by a member of the public.

The family are concerned about the level of care Keaton received whilst in the Tramwell Unit, including the lack of assessment past 72 hours, failure to assess him under the Mental Health Act, the decision to allow Keaton to leave the unit, and the contact with the family who had made clear they did not agree to leave being granted.

HM Assistant Coroner Karin Walsh’s inquest conclusion highlighted a number of issues in the care Keaton recieved, including that:

  • A more in-depth assessment was warranted by Keaton’s behaviour, which was starting to present a pattern.
  • Ten days of admission [beyond the mandated 72 hours] fell well below the standard expected, and an admission meeting should have been held sooner.
  • Communication with the family should have been better.

The coroner also commented that the information provided to the police when Keaton was reported missing was not the standard the Trust would have hoped for, which the Trust themselves recognised. Overall however, the coroner concluded that “things could have been better for Keaton but ultimately it would not have made a difference.” Her conclusion was that Keaton’s death was a suicide, which she did not believe could have been foreseen by those involved in his care, including by professionals and family members. She made no criticism of those managing Keaton’s care, and noted that Keaton’s mother went above and beyond to support him.

Jessica Talbot, Keaton’s mother, said: “I feel let down by the Trust and Keaton’s overall care. I believed he was in the best place for treatment. I think he should have been assessed and detained under the Mental Health Act. On doing this he would not have been allowed unescorted leave on his own so soon, and more assessments would have been carried out. I thought the coroner would have been a lot more critical of the Trust. I accept they have made changes and I hope these changes continue, and I hope to never hear about another family going through what we have.”

Jodie Anderson, Caseworker at INQUEST, said: Keaton’s family are rightly concerned by the decision to grant unescorted leave in circumstances where he was so unwell and in need of specialist care. There is a systemic issue in relation to mental health providers not properly assessing the appropriateness of leave, including communicating with the family and managing risk. Conversations must be had going forward about the key role that families play and their vital input on decisions about the care and treatment of their loved ones.”


For further information, interview requests and to note your interest, please contact Lucy McKay on 020 7263 1111 or [email protected]

Keaton’s family are represented by INQUEST Lawyers Group members Neil Cronin of Southerns and Matthew Stanbury of Garden Court North Chambers. The family are supported by INQUEST caseworker Jodie Anderson. The inquest is an Article 2 inquest held without a jury.

Other Interested persons represented are Gateshead Health NHS Foundation Trust and Northumbria Police.

Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.