Jury found that inadequacies in the care of Paul Hirons led to his death at the Broadoak Unit

16th April 2016

Paul Hirons was a 37 year old father, husband and teaching assistant who loved art and had a wonderful ear for music. He was very close to his family and was a kind, obliging man who people went to when they needed help and advice.

On Monday 5th January 2015, Paul was not behaving like his normal self. It was clear to his family that he was suffering from a sudden onset of severe depression and delusions. They took him to see his GP on Thursday 8th January. His GP immediately recognised that he was very unwell and referred him to the Royal Liverpool Hospital A&E where doctors confirmed that he was suffering from severe depression and delusions caused by psychosis.

This was the first mental health episode Paul had ever suffered and the A&E team at the Royal found him a bed on Albert Ward at the Broadoak Unit, a mental health crisis unit run by Merseycare NHS Trust. His family took him to Broadoak Unit, believing it was a safe place for Paul to stay, where he would be looked after in a supportive environment and helped to get well.

Paul was admitted to the Broadoak Unit at 7.40pm on Thursday 8th January 2015. He was found hanging in the dormitory he shared with other patients at 12.12pm on Tuesday 13th January 2015, having spent just 5 days in the Unit. He died as a result of his injuries on the 17th January 2015.

His inquest  heard extensive evidence related to the inadequate standard of care he had been given while at the unit.  The jury unanimously found that, as a consequence of the failings of Paul’s environment and care, it was not possible to form a clear opinion about what his intentions were and whether he intended to take his own life.   In a critical narrative conclusion, the jury found that the care provided to Paul at the Broadoak Unit was inadequate and that failings in his care had contributed to Paul’s death. They found that there were numerous failings in Paul’s care:

  • When Paul was received at Broadoak Unit, it was initially recognised that he was at real, imminent risk of self harm. During Paul’s stay, however, that risk was not managed adequately or effectively.
    ● Paul’s risk of self harm was not reviewed adequately or effectively.
    ● The procedures for documenting events and reviewing Paul’s care plan were not followed appropriately.
    ● Observation levels and risk management were inadequate.
    ● Record keeping was inaccurate.
    ● Family member concerns were not documented or taken into consideration.

The court heard that Merseycare NHS Trust accept responsibility for Paul’s death and had served a statement setting out their position two weeks before the Inquest.

Leanne Dunne, solicitor representing the family, said:

With the current focus on mental health awareness, and in particular the recognition that male suicide is the single biggest cause of death in men under 45 in the UK, it is shocking that Paul was let down by the NHS when his family had sought their help to care for him whilst he was ill.  The jury’s critical narrative conclusion details the failures in Paul’s care which related to multiple failures on a very basic level.  The Trust’s acceptance that they are responsible for Paul’s death and the jury’s critical findings demonstrates that this sadly was an avoidable death.”

Helen Milne, Paul’s partner said on behalf of the family:

"Paul was a sweet, kind, funny and unassuming man, a brilliant father and most loving and supportive partner.  The ongoing shock and grief felt by Paul's family and wide circle of friends who sorely miss him is difficult to put into words.  We believed that Paul was in the best possible place of safety only to discover he was effectively left alone for the majority of his time in Broadoak..
We are all devastated by Paul's death but are pleased that the jury recognised the systemic failures in the care that was provided to him and are thankful for the trust's sensitivity and transparency.
Until mental health services are given parity with physical health services in recognition and funding this kind of tragedy can never be avoided."

INQUEST has been working with the family of Paul Hirons since January 2015.    The family is represented by INQUEST Lawyers Group members Chris Topping and Leanne Dunne from Broudie Jackson Canter Solicitors and Emma Favata of Garden Court Chambers.