Blog
Brain injury: the hidden impact of isolation
Kirsty Allen
Our Head of Clinical Negligence, James Bell, and barrister, Robert Oldham of 12 Kings Bench Walk Chambers recently represented the wife of a man in his late forties who tragically died by suicide, at a 7 day Article 2 inquest into his death.
In May 2025, the Deceased suffered a serious mental health crisis, including a manic episode, and was taken by ambulance to hospital. Prior to this crisis, he had been receiving support from a privately instructed psychiatrist and had been under the care of a local Home Treatment Team (HTT). He had recently made preparations to take his own life and had previously demonstrated suicidal ideation on another occasion.
On arriving at hospital, the Deceased was assessed by the Psychiatric Liaison Service, which concluded that he should not be permitted to return home given the risk he posed to himself. Despite this assessment, it was agreed that he would be offered a stay at a respite facility as a voluntary resident, free to come and go without restriction. It was planned that while at the facility he would receive support from the HTT — notwithstanding the fact that he had told hospital staff that HTT support had not worked for him at home.
Staff at the respite facility accepted his placement despite harbouring concerns, knowing that his movements could not be restricted and that HTT support had previously proved ineffective for him. The Deceased was taken to the respite facility the following evening. The next morning, he left. He was later reported as a missing person and searched for by police. Tragically, his body was found in a wooded area several weeks later. The cause of death was established as hanging.
The Coroner concluded that the Deceased had been provided with ‘the opportunity to take his own life’ having been referred to and accepted by a respite facility which did not meet 'his complex and significant mental health needs'. The Coroner noted that these circumstances arose because the Trust failed to give 'sufficient consideration to a voluntary admission to hospital' and decided to refer the Deceased to a respite facility 'when this did not comprehensively address the risk' that the Deceased 'posed to himself and the support required for his mental health needs.' It was further concluded that the respite facility 'failed to reject the referral when it should have when it was provided with information that demonstrated that the facility was not an appropriate environment', since it could not refuse to let the Deceased leave and it knew that HTT support was what would be provided but that it had not worked for him.
James Bell comments:
This is a profoundly sad case in which a vulnerable man was catastrophically failed by the very mental health services that were responsible for his care and safety. The inquest has provided clarity about the failings that occurred - both in the decision to place him in a respite facility wholly unsuited to his needs, and in that facility's acceptance of the referral. We hope that the findings bring some measure of comfort to our client in understanding what went wrong, and that lessons are learned to prevent similar tragedies in the future."
Client comment:
I’m really happy with the representation I received from James Bell and his team at KN and Robert Oldham. They were very professional, thorough and supportive throughout a difficult and emotional process. We would not have had such a detailed and critical narrative finding without all the work they put into this.”