26 October 2023

Before HM Coroner Zak Golombeck 
Manchester City Coroner'sCourt
23 – 25 October 2023  

Niall Tyrrell, 28, was found ligatured whilst an inpatient at Juniper Ward, the intensive psychiatric care unit at Park House Hospital, Manchester on 2 May 2022. Now a jury has found that Niall died by suicide contributed to by neglect. 

A father of two, Niall was described by his family as the "life and soul of every party" and the "most amazing and happy person that everybody loved.’"

Niall had a long history of depression and complex mental health needs, including a diagnosis of Obsessive Compulsive Disorder (OCD) and Emotionally Unstable Personality Disorder (EUPD).   

Niall was first detained at Mulberry Ward on 9 April 2022. He was allowed escorted leave if accompanied by his mum.    

On 21 April, Niall was allowed to leave the ward after pretending that his mother was downstairs to collect him. She had warned staff the day before, and again that same day, that this would not be true. 

Niall absconded and later phoned his mum threatening to take his own life. Police were called and took Niall to hospital. He was found to be suffering from a rare condition due to medication side effects.   

On 26 April, Niall attempted to ligature on the hospital ward. He was placed under constant observations and two members of staff had to be with him at all times. 

The next day, Niall was returned to Mulberry Ward. He again absconded and was found by his family on top of a bridge. When he was returned to the ward, he was placed on one-to-one constant observations 

On 28 April, a decision was made to transfer him to Juniper Ward at the same hospital, and his observations were reduced to one every 15 minutes.   

On 1 May, Niall’s mother phoned the ward expressing how worried she was about Niall’s safety and asked them to keep a close eye on him. The next day, Niall was found ligatured and taken to hospital. He died later that day. 

The jury concluded that Niall died by suicide contributed to by neglect.  

During the inquest, the Trust admitted to failures in Niall’s care. They said: “It is accepted that Niall should have been subject to 1:1 observations whilst he was on Juniper Ward from the time of his admission on 28 April 2022 until his case had been reviewed by a multidisciplinary team meeting, which had not occurred by the time of his death on 2 May 2022. It is admitted that this was a failure in Niall’s care.” 

Joanne Tyrell, Niall’s mother, said: We will never stop missing Niall, our gentle giant,but believe this inquest has brought him justice, and can only hope that others suffering from acute mental ill health will be kept safer.” 

Ruth Bundey, representing the family said: There were serious failures in the management of Niall’s clinical care - care which should have mitigated known ligature risks. On the last day of his life, his mother alerted ward staff time and time again to his suicidal ideation, but even then the one to one observation and contact he needed were not put in place.” 

Selen Cavcav, Senior Caseworker at INQUEST, said: If this Trust, which has recently been rated as ‘inadequate’ by the CQC, had put lifesaving measures in place, Neil’s death could have been prevented.  

Families should be able to trust that mental health services will keep their loved ones safe in times of crisis. In inquest after inquest we hear evidence of safety mechanisms falling by the wayside as findings and recommendations are forgotten about. 

That’s why we need a National Oversight Mechanism to address this shocking accountability gap and ensure that when recommendations are made following deaths they are not lost, ignored or left to gather dust. This would do justice to bereaved families and help save lives."



For further information, interview requests and to note your interest, please contact Leila Hagmann on [email protected]. 
The family are represented by INQUEST Lawyers Group member Ruth Bundey of Harrison Bundey Solicitors. They are supported by INQUEST Senior Caseworker, Selen Cavcav

Other Interested Persons represented are the Greater Manchester Mental Health Trust (‘GMMH’). 

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

Other related deaths 

Greater Manchester NHS Trust has recently been graded ‘overall inadequate’ by the Care Quality Commission. 

  • Charlie Millers, 17, died in December 2020 whilst an inpatient at Prestwich Hospital (run by the same trust). An inquest into his death was adjourned earlier this year due to a police investigation into the circumstances around his death. Media release.

  • Rowan Thompson, 18, died on 3 October 2020 whilst an inpatient at the Gardener Unit, a medium secure adolescent mental health unit in Prestwich Hospital. Rowan was non-binary. An inquest in December 2022 found that their death was contributed to by neglect due to the failure to communicate the findings of blood tests. Media release. 

  • Ania Sohail, 21, died in June 2021 whilst at Junction 17 in Prestwich Hospital. An inquest jury concluded in January 2023 that her death by suicide was 'contributed to by the ineffectiveness of searches, post leave assessment and safety plans which reflected Ania's risk'. See media coverage.