26 November 2021

Before HM Senior Coroner Alan Wilson
Blackpool and Fylde Coroner’s Court

15- 25 November 2021

An inquest into the death of a son and mother, who had both been under the care of the same mental health team within Lancashire and South Cumbria NHS Foundation Trust in Blackpool, has concluded with a range of findings. The family are now speaking out about the failing services and their concerns about the inquest, which did not fully reflect their concerns.

The coroner has however indicated that he is going to make a Prevention of Future Deaths report to the Minister for Care and Mental Health at the Department of Health and Social Care. This will highlight his concern that Children’s Social Care do not automatically continue their involvement in a child or young person’s care while they are an inpatient.


Marshall Metcalfe was 17 when he died on 7 May 2020. He was pronounced dead at Royal Preston Hospital after falling from a car park in Blackpool. His mother Jane Ireland, 44, died on 7 June 2020.

Marshall loved football and supported Burnley FC. He also enjoyed fishing and gaming. He was a fierce and loyal friend. The family are heartbroken that they will never see him grow up and fulfil his dreams. Since October 2017, Marshall had been under the care of Child and Adolescent Mental Health Services (CAHMS) run by Lancashire and South Cumbria NHS Foundation Trust. He had been diagnosed with schizophrenia and prescribed antipsychotic medication.

Marshall had twice been a sectioned inpatient in a children’s mental health unit, Cove in Heysham, most recently in January 2020, four months before his death. At the time of his death, he was under the care of the local Early Intervention Service. A review of his care was scheduled in March 2020 but was delayed due to the pandemic and not rescheduled.

Marshall’s mother Jane Ireland was a mum of three. Her family describe her as a fun and loving person who brightened every room she walked in to. She was a talented makeup artist and worked on theatre productions and photoshoots. She was also a qualified Reiki therapist and dreamed of opening a retreat.

Jane developed mental ill health in the years prior to her death, following serious violence from an ex-partner. Her daughter Holly fought to get her help to access services. In 2017 she was sectioned. She was discharged six months later into the care of the Lancashire and South Cumbria NHS Foundation Trust community mental health team, including the adult Early Intervention Services. She remained under their care until she was discharged from their services in December 2019, six months before her death.


The inquests were joined following submissions from the family which reflected their longstanding concerns that the Trust had failed to treat Marshall and Jane as family with experiences of significant trauma. An independent expert instructed by the coroner, Dr Draper, agreed with these concerns, describing a lack of any safeguarding system to link the two together. The family are disappointed that the coroner found that, on the balance of probabilities, this would not have changed the outcome for either Marshall or Jane.

Following her experience of domestic violence in 2010, Jane developed severe psychosis and was eventually sectioned in August 2017. This was only after her daughter Holly repeatedly raised concerns about her mental health and had to write to her MP to get Jane help. Jane was discharged in December 2017. Her son Marshall had only just turned 15, but from this point onwards, his mental health would be inextricably linked to Jane’s and he too developed psychosis.

Marshall was pronounced dead at Royal Preston Hospital after jumping from a car park in Blackpool. Two years earlier Marshall had told professionals that he had been to the top of a tall building intending to jump, which is how he ultimately went on to die. The inquest concluded his death was a suicide.

Marshall had previously been admitted under section to the Cove Children and Adolescent inpatient facility on two occasions for 131 days and 315 days. The court heard that the average length of stay is far lower at four to six weeks. Marshall hated the Cove. He was discharged into Jane’s care in January 2020, despite not having improved significantly.

The coroner found that other alternative placements had not been considered and that Children’s Social Care had not been involved in the discharge planning, as they should have been. The expert described the discharge into Jane’s care as abrupt, precarious and inappropriate without considering alternative placements.

The coroner found that Jane’s mental health had been stable with no major relapse. The family strongly disagree with this finding, which fails to reflect the evidence heard at the inquest. Holly was raising serious concerns about her mum’s mental health in March, April and October 2019 and there were concerns raised by professionals in June and July 2019.

Jane was discharged from mental health services at her own request in July 2019, despite continuing to experience symptoms of psychosis and refusing to take anti-psychotic medication. In December 2019, a month before Marshall’s discharge, Jane went to her GP with concerns about her own mental health, these were escalated to the Trust’s mental health team but never passed on to the Consultant Psychiatrist who had treated Jane, or to Marshall’s mental health team.

The coroner found that there was no risk assessment in place at Marshall’s discharge and that the referral to Children’s Social Care did not happen for another three months. The coroner described evidence about the discharge from Marshall’s Care Coordinator as ‘unimpressive’ and found that the referral should have taken place much earlier.

The coroner also found that there was no indication that Marshall would relapse in the months before he died and that any failings in his discharge did not contribute to his death. Having heard the evidence, the family strongly feel that Marshall would have survived had care professionals taken their concerns about Jane’s mental health more seriously and had an alternative placement been considered.

The family strongly feel that throughout his care insufficient efforts were made to get down to Marshall’s level and to engage him in a way that was meaningful to him.

Jane died after a methadone overdose exactly one month after Marshall. The coroner found that he could not say on the balance of probabilities whether she had intended to take her life, given evidence that she had previously taken an accidental overdose as a way of coping with the more distressing symptoms of her condition. The coroner did not believe that the Trust should have provided Jane with more support after Marshall’s death, a finding that the family strongly disagree with.

The evidence highlighted that the issues in Marshall’s case lie in the interface between mental health services and Children’s Social Care. Those involved in these agencies showed confusion and uncertainty about their responsibilities in this area when giving evidence to the inquest, particularly witnesses from the Trust.

The court also heard evidence from a Public Health official from Blackpool City Council, who explained that the Council had been aware of the Sainsbury’s car park, where Marshall died, as a suicide hotspot since 2017. However, because the Council does not have any regulatory power to force private organisations to take action to reduce suicide risks, it took three years and at least two further deaths - including Marshall and an unnamed looked after child - before the work was eventually carried out.

After the death of children there is a Sudden Unexplained Death in Childhood process which is intended to identify support needed for family members, based on their needs. The family argued that, given Jane’s mental health vulnerability, the risks posed in terms of her own relapse and subsequently in terms of risk to herself (whether through accidental means or suicidal intent), the risk should have been obvious and more should have been done to provide support tailored to her particular background and vulnerabilities.

However, Jane was not flagged up as a risk in need of more intensive support. Instead, her daughter Holly was left repeatedly trying to access help for her. Her attempts were ignored and concerns went unrecognised. The family are disappointed that the coronial process has reflected the approach of healthcare professionals while Marshall and Jane were alive, in failing to take their concerns seriously.

Holly Ireland, sister of Marshall and daughter of Jane, said: “The system is broken and has failed me yet again after so many instances over the last decade. These have been the hardest times of my life and I don’t feel that anybody else has should ever have to go through what me and my family have, but sadly this is becoming the case for far too many - not just on this country but around the world.

The coroner has been presented with an overwhelming amount of evidence of what I believe is systemic failure and negligence across multiple services and professionals at all levels. The fact that he can make conclusions which completely ignore so many key points and factors, in an effort to create a narrative and justify complete injustice, is just sick and wrong and heart-breaking. I believe it shows that the system is corrupt at its core and not there to genuinely care for people.

I do however take some positive in how much light the inquest has shed on the failures in the current system. I will continue to fight against it for my loved ones and for all other people out there who have been through or are going through grief at the hands of the mental health system! It is also positive that one preventing future deaths report has been carried out as a result of the inquest. It should ensure that Children’s Social Care must be involved and carry out proper risk assessments during the discharge of young and vulnerable patients in the future. While I am glad that this report is being made, I still can’t say I’m at all happy with the inquest’s outcome.

No preventing future deaths report has been carried out with regards to the car park where Marshall died. We heard from a council representative that they made Sainsbury's aware of the dangers from 2017. Yet it took until 2020 and Marshall's death for permanent barriers to be put up. The council representative told the inquest that they have no power to compel private companies take any steps to make known suicide hot spots safer. This lack of regulation puts future lives at risk across the country.

The coroner ignored so many facts in his conclusion and sided with supposed professionals who I believe were obviously incompetent. Some of which the coroner even described as “bad witnesses” over clear reason, fact, heart and conscience!

I still have a lot to process but this is not the end of my fight to change this broken system we are all currently subject to. I will be pushing to further the cause and hoping in future to link with other families going through this who are fighting the same fight!!”

Holly has now started a campaign to highlight the lack of support for mental ill health and bring together other campaigning families called Marshall’s Movement.

Lucy McKay, spokesperson for INQUEST, said: Time and time again we see families’ concerns being ignored, and mental health and social services failing to communicate and provide holistic support. These are the fundamentals of care for anyone with mental health or support needs.

To see a family lose both a son and a mother due to these kind of basic and well documented issues is as tragic as it is deeply frustrating. We must see national action and investment in mental health and local services to enable joint up support. While professionals need to create a culture shift towards listening to family advocates like Holly, so people are no longer forced to fight for the lives of people they love.”

Lucie Boase of Broudie Jackson Canter solicitors said: “After an almost decade-long fight to try to ensure appropriate care and treatment for her mum and younger brother, Holly Ireland has persistently tried to shine a light on the deficits in the healthcare system that led to their deaths so that other families will not suffer the same devastation that she and her family, including her younger sister and grandmother, have had to endure. Holly’s fight goes on and she deserves all the support going forward.”


For further information and interview requests please contact Lucy McKay on 020 7263 1111 or [email protected]

Follow Marshall’s Movement on marshallsmovement.org.uk, Facebook, Instagram and YouTube.

The family is represented by INQUEST Lawyers Group members Lucie Boase of Broudie Jackson Canter solicitors, and Ciara Bartlam and Mira Hammad of Garden Court North Chambers. The other interested persons represented are Lancashire and South Cumbria NHS Foundation Trust and Lancashire Council.

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