18 September 2023

Before Assistant Coroner Rachel Spearing
Hampshire, Portsmouth and Southampton Coroner’s Court, 
11-15 September 2023

Michael Holland, 45, died from an overdose on 2 December 2021, hours after Sussex police and paramedics found him  in the act of self-harming during a welfare check. He died only three days after being discharged from Langley Green Hospital, Crawley, after being held as an inpatient under section. A coroner has concluded that his medical cause of death was morphine toxicity and bronchopneumonia. 

Michael was a qualified personal trainer from Crawley in West Sussex. He had an intensely curious mind, and was fascinated by the natural world and conservation. He was never happier than when he was out in woodland. He was also an exceptionally talented artist, with a photographic memory.  

Michael suffered chronic pain as a result of an unprovoked attack in 2012. In the last few years of his life, he suffered from serious mental health issues manifested by severe paranoia. He was sectioned several times as a result of suicide attempts and self-harm, including following three overdoses in January 2020.

The Covid-19 pandemic greatly exacerbated Michael’s mental ill health. In 2021 he began experiencing psychosis. Michael became paranoid and frequently thought that people were trying to harm him.

On 8 October 2021, Michael’s mother called the police after becoming increasingly concerned for his welfare. Officers proceeded to detain Michael under Section 136 of the Mental Health Act 1983 (MHA). 

Langley Green Hospital

After an initial assessment at Crawley Police Station and a brief stay at Mill View Hospital in Hove, Michael was taken to Jade Ward, Langley Green on 11October 2021. This was despite concerns raised by Michael’s mother about the poor quality of aftercare provided to patients discharged from the hospital.

The following day, whilst on the ward, Michael was able to self harm so seriously that he  had to be taken to A&E. He was discharged the next day back to Jade Ward.

Over the following weeks, Michael continued to have delusional and paranoid beliefs that he would be harmed and believed that he had witnessed his mother’s murder.

He expressed these beliefs to his mother through texts, and she relayed the content of these messages to the ward staff. Despite this, towards the end of November, preparations were being made to discharge Michael back into the community.

Michael’s mother expressed grave concern that Michael’s discharge was being planned prematurely. She alerted staff to the fact that Michael was still demonstrating concerning delusional and paranoid beliefs and she did not feel he could be kept safe in the community. 

On 23 November, there was a discharge meeting with clinicians which involved Michael and his mother. There was no specific discussion recorded about the plan to discharge Michael home with only seven days of medication. 

The next day, Michael was transferred to a different ward, with preparation still in place for his discharge. Two days before Michael was due to be discharged he was recorded as having only one hour’s sleep.

Post discharge

On 29 November, Michael was discharged from Langley Green. The lead practitioner had taken annual leave and as such, the planned post-discharge face-to-face follow-up was not completed as would be expected.

Giving evidence, both consultant psychiatrists responsible for Michael’s care in detention agreed that Michael was at risk of an overdose from opiates following his discharge, especially in the first 72 hours. However, there was no evidence to show that this specific concern was explicitly recorded. 

Two days after his discharge, on 1 December, staff were unable to contact Michael as part of the 72 hour follow-up protocols. Michael’s mother had informed staff that she had a spare key to his flat, but this was not recorded on Michael’s discharge plan. 

The duty worker tasked to attend Michael’s property did not have contact details for Michael’s mother. When there were difficulties in accessing Michael’s property, Michael’s mother was not contacted. 

This led to a potential missed opportunity to enter Michael’s property non-invasively for a check to be undertaken by mental health professionals. Instead, paramedics were asked to conduct a welfare check and attended Michael’s home, accompanied by police. 

Michael did not open the door, and at around 22.50 on 1 December officers forced entry into his house. They found Michael holding a knife, with visible self-harm marks. He disclosed that he had taken “shit loads” of his morphine medication.

Several packs of medication were found in the kitchen bin, including an empty packet of morphine medication.  Michael could be seen on body worn footage hunched over. He did not get up from his bed during the 20 minute period in which the police and ambulance were present. He was reluctant to make eye contact, and it was hard to understand him. He repeated twice, “I can hardly stand up straight at the moment”, adding, “I can hardly move right now”.

The paramedics made the decision to leave Michael alone in his flat on the basis of his reassurances to them and the information he provided them. One paramedic stated, “usually with a morphine overdose it happens quick”.  

At 23.53 that night, after the welfare check had been completed, Michael sent a text to a patient at Langley Green to say that he’d taken an overdose. Although ward staff were alerted, no further steps were taken to request re-attendance of emergency services and this text message did not lead to a 999 call being made. 

Around 13 hours after Michael was seen by emergency responders, he was found dead in his flat from the toxic effects of a morphine overdose. 

The findings of the inquest highlighted the following failures:

  • Shortcomings in the system allowed Michael’s repeat prescribed medication to be ordered from his GP surgery during the time in which he remained an inpatient.    
  • Face to face contact expected by Michael’s lead practitioner during the 72 hour follow-up period was sub-optimally replaced with telephone contact by ward staff.
  • There was a failure to communicate difficulties in completing a welfare check within the critical 72 hour follow-up period following discharge to Michael’s mother. This was contrary to care policies.
  • Following the text message sent by Michael to another patient on the ward indicating that he had taken an overdose, less than an hour after the paramedics’ departed, there was a missed opportunity to alert emergency services to a possible overdose and request urgent re-attendance by the paramedics.

Michael’s mother said: "The Court has recognised that there was a failure to communicate the discharge plan and a failure to follow-up with me when Michael could not be contacted during the 72 hour window following his discharge. It is vital that mental health teams make full use of the unique insight that a family can have in managing a person’s risk.

During Michael’s stay at Langley Green, I found myself continually having to contact the hospital in order to be kept updated. Approaching discharge, I repeatedly told staff, “He won’t answer the phone, contact me first”. This request was not listened to.

I am convinced that if I had been contacted after Michael’s discharge, we would not be here today."

Jenny Fraser and Jazz Balmer of Fosters Solicitors, representing the family, said: “It has been a privilege to represent Michael’s Family in this tragic case. It has been a long process to reach the inquest’s conclusion, and tireless efforts have been made throughout to ensure that the full facts are brought to light.

Failures have been recognised and it is sincerely hoped that improvement will now be made to prevent similar failings from reoccurring in future circumstances.”

Jodie Anderson, Senior Caseworker at INQUEST, said: It is haunting that Michael’s mother, like so many others whose loved ones have died whilst under the care of mental health services, prophesised that a premature discharge would lead to his death. It is disappointing that the inquest did not go further in exposing the cacophony of failures around communication, chronic pain management, medication and risk.

Once again we see failures to communicate vital information to families. Lessons learnt is meaningless and hollow. Families expect and deserve a voice that is heard, instead of the professional gaslighting that they are so very often met with."



For further information, please contact Leila Hagmann on [email protected] or 020 7263 1111.

A photograph of Michael is available here.

The family are represented by INQUEST Lawyers Group members Jenny Fraser and Jazz Balmer of Fosters Solicitors and Jonathan Metzer of 1 Crown Office Row. They are supported by INQUEST Senior Caseworker Jodie Anderson.

Other Interested Persons represented at the inquest are Sussex Police, Sussex Partnership NHS Foundation Trust (SPFT) and Sussex East Central Ambulance (SECAmb).

In January 2022, an investigation by the Telegraph revealed that between 2016 – 2021, 360 patients took their own lives after being treated by Sussex Partnership NHS Foundation Trust (SPFT).

  • KA, 29, died whilst an inpatient at Langley Green Hospital in January 2021. The inquest in 2021 found her death was contributed to by neglect.
  • Christopher Swain, 38, took his own life whilst an inpatient at Langley Green hospital in September 2019. A report to prevent future deaths was issued following concerns around observations, reviews and record keeping.
  • James Herbertson was fatally hit by a train in April 2019 after being discharged from Langley Green Hospital despite his family concerns. A report to prevent future deaths was made regarding failure to communicate the discharge to James’ family.

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