31 January 2019

Before Area Coroner Jonathan Leach
Wakefield Coroner’s Court
28 - 31 January 2019

The inquest into the death of Timothy McComb has today concluded. Timothy was 38 when he died a self-inflicted death in transitional supported housing, Cottingley Court in Leeds, on 26 August 2016. He was under the care of East North East Leeds Community Mental Health Team, and had complex needs around mental ill health, substance addiction, and a learning disability.  

After a three day hearing, the coroner directed a short form narrative, and the jury concluded Timothy died of suicide. Timothy’s family fought to have a thorough inquest with a jury (under Article 2) and were forced to crowdfund for legal representation. They are disappointed with this conclusion.

Timothy’s family describe him as a ‘Peter Pan’, who was fun-loving and always supportive to others. In the years before his death they felt he had changed and needed help. In a Pen Portrait read to the court, the family said Timothy had stopped interacting with his much-loved nephews and niece, but instead spoke to a doll he called Dennis that he carried with him everywhere.

Timothy initially became involved with the Mental Health Services after being admitted to hospital under the Mental Health Act in 2014. He had spent periods as a mental health inpatient. Although there was no formal diagnosis it was thought that Timothy had experienced psychosis. In December 2015, a Consultant Psychiatrist noted that he believed Timothy had a learning disability and difficulty coping with social stressors. However, a follow up appointment was missed and, despite further referrals and concerns from various professionals, Timothy was not assessed again.

Between June and March 2016, Timothy had numerous contacts with Leeds Mental Health Services, including visits to A&E and the Intensive Community Service. Around this time, Timothy was allocated a Care Co-ordinator from East Leeds Community Mental Health Team. On 11 July 2016, Timothy was moved to Cottingley Court, transitional supported living for people with mental health needs. However, they raised concerns regarding the appropriateness of this placement.

The inquest heard evidence from Timothy’s GP, Dr Hari Pai, who felt the allocated Care Coordinator was inappropriate for someone with complex mental health needs. He noted that an increasing number of his patients were presenting themselves at A&E due to inappropriate care coordination. The inquest heard that in the lead up to his death, Timothy’s Care Coordinator went on leave but was not replaced with a suitable worker.

On 22 August 2016, Timothy was taken to A&E with a suspected overdose.  He expressed suicidal ideations arising from a fear of becoming homeless. In hospital he was identified as a significant risk of suicide. On the morning of 26 August 2016 Timothy was found hanging in his room. His door was open. Timothy’s family believe that his death was not an intentional suicide, but a cry for help.

Katie Siobhan, Timothy’s sister, said: We are hugely disappointed by this conclusion.  Timothy was a loving son and brother who was desperately trying to find support for his complex issues.  We have fought for an Article 2 inquest, been refused public funding, forcing us to fundraise to pay for representation, face a Coroner who refused to call witnesses and even refused to let us show a photograph of Timothy, further dehumanising him.

The whole process has been frustrating and traumatic. We do not feel our concerns have been addressed. At times, we felt how Timothy must have felt, shut out and excluded, like we are invisible and that our questions didn’t matter.  We now call for action for a clearer referral process and support for people like Timothy in the hope that lives will be saved.”

Anita Sharma, Senior Caseworker at INQUEST who supported the family, said: “INQUEST is increasingly contacted in relation to people with multiple needs, who are falling through the gaps between services. The NHS has long been aware of shortcomings in care for those with multiple diagnosis, yet significant numbers are left without access to treatment resulting in self-inflicted deaths without proper scrutiny of the circumstances. 

It is paramount that inquests explore the full range of issues, as an opportunity to address ongoing and widespread failings. It is disappointing that the coroner is not considering a prevention of future deaths report. This is missed opportunity to protect those in similar circumstances who remain at risk.”

Sara Lyle of Minton Morrill solicitors, who represented the family said: Part of the purpose of inquests is to ensure necessary changes are made so failings are not repeated, but families are forced to fight to make that happen. Grieving families should not be expected to deal with complicated legal processes, without legal aid to assist their representation. Particularly when public bodies have unlimited access to funds for representation. This inequality needs to urgently be addressed to support bereaved families and protect lives.”


For further information and to note your interest, please contact Lucy McKay and Anita Sharma on 020 7263 1111 or email Lucy and email Anita.

INQUEST has been working with the family of Timothy McComb since January 2017. His family are represented by INQUEST Lawyers Group member Sara Lyle of Minton Morrill solicitors, and Andy Fitzpatrick of Garden Court North Chambers.