15 January 2021

UPDATE: The inquest conluded on 21 January. See media coverage of the conclusions

Before HM Senior Coroner, Ian Arrow
Plymouth Coroner’s Court, 1 Derriford Park, Plymouth PL6 5QZ
Opens 10am 18 January 2021, expected to last four days*

Ross Mackenzie, 40, died on 2 December 2018 from drowning at Plymouth Sound. Ross had a history of mental ill health and was under the care of community mental health services, managed by Livewell Southwest at the time of his death. An inquest into his death opens on Monday 18 January.

Ross was born in Southport, Lancashire but spent all of his adult life in Plymouth, Devon. His family described him as a gentle, kind individual who loved music. He was an accomplished guitarist who wrote music and played in local bands.

Ross was diagnosed with schizophrenia when he was seventeen years old. On 1 December 2018, the day prior to his death, Ross suffered an acute psychotic episode which resulted in him being referred to Plymouth Derriford hospital by NHS 111. Ross spent approximately seven and half hours at the hospital and left without seeing a psychiatrist. He was prescribed 3 x 5mg of Diazepam to last two days.

The psychiatric home treatment team were contacted but they did not assess Ross that evening, instead agreeing to carry out a further assessment the following day. Sadly, Ross was found deceased before this further assessment could take place.

In February 2020 the NHS Devon Clinical Commissioning Group (CCG) conducted a review of 11 serious incidents which resulted in death or significant self-harm between May 2018 and June 2019. In five of these cases (including Ross) patients had died in the community within 72 hours of presenting at the Emergency Department at Derriford Hospital and had been seen by or referred to the Liaison Psychiatry service. The CCG report concluded that there were major issues with the treatment received by patients suffering from mental ill health and their report identified 25 recommendations to address the perceived shortcomings. The CCG made the decision not to make their report public.
The family hope the inquest will consider:

  • The excessive length of time Ross had to spend in a busy Emergency Department environment whilst experiencing a high level of distress, prior to having a mental health assessment.
  • The lack of appropriate mental health expertise at the hospital to deal with situations similar to Ross.
  • The failure to prescribe appropriate medication.
  • The “out of hours” care afforded to mental health patients.



For further information, interview requests and to note your interest, please contact INQUEST Communications Team: 020 7263 1111 or [email protected][email protected]. A photo of Ross is available here
Due to the coronavirus pandemic journalists are asked to attend remotely via Microsoft Teams. To apply for remote access you must email [email protected] by 3pm one working day before you wish to attend.
Ross’s family are represented by INQUEST Lawyers Group members Craig Court of Harding Evans Solicitors and Sophie Walker of One Pump Court Chambers. The family are supported by INQUEST caseworker Selen Cavcav.

The other interested persons represented at the inquest are Livewell Southwest and Plymouth Hospital NHS Trust.

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