Inquest concludes into the death of James Lockett, whose medical cause of death was recorded as unascertained

Before HM Assistant Coroner Joanna Lees

North Wales (East & Central) Coroners Court

Monday 1 April to Friday 5 April 2019, lasting 5 days

James Lockett, 32, was found deceased at his home in Colwyn Bay on 6 December 2016.

At James’ inquest, the coroner heard that James participated in many community activities; he attended church, volunteered, and trained at the local martial arts academy. James would also go to the cinema almost every weekend and enjoyed going on days out with his family.

On 5 April 2019, HM Assistant Coroner Joanne Lees recorded an ‘Open’ conclusion following 5 days of evidence.  She will consider evidence in relation to a Prevention of Future Deaths Report in a further hearing on 2 May 2019.

The Coroner made criticisms of the absence of joined up communication between North Wales Police, Conwy County Council and Betsi Cadwaladr University Health Board, who were responsible for the Community Mental Health Team (CMHT). She emphasised that there were a number of missed opportunities by the services to share information about James.

Significant concerns were raised surrounding monitoring James’ medication and the care he received by the CMHT. The Coroner noted that there was a concerning lack of action by James’ Care Coordinator to establish more information about James’ arrest in order to make an assessment of his needs. The Coroner indicated that she will address these concerns further when considering a Prevention of Future Deaths report and she has requested details of the Care Coordinator’s Professional Governing Body and professional registration number.

The Coroner also raised concerns in relation to preparation and planning by North Wales Police for arrests involving people recorded on the Records Management System as diagnosed with Schizophrenia. This will again be dealt with on 2 May 2019.

In 2004, James had been diagnosed with paranoid schizophrenia. At the time of his death, James was under the care of the Betsi Cadwaladr University Local Health Board (BCULHB) and was prescribed the anti-psychotic medication clozapine.

The inquest heard that in July 2016 James had been arrested in relation to an allegation of assault at a local cinema. James voluntarily attended St. Asaph police station on three separate occasions to meet his bail requirements, and on each occasion was assessed as requiring an appropriate adult.

The inquest heard that in September 2016, an officer had concerns about James and the possibility that his mental health was deteriorating since his arrest in July. The officer, PC Williams, considered that James was a vulnerable adult and completed a referral to the Public Protection Vulnerable Persons Unit. They in turn intended to share it with James’ community mental health team. However, the inquest heard that the email was never received and therefore James’ Care Co-ordinator was not made aware of the Police’s concerns.

In November 2016, an arrest warrant was issued for James following him not attending Court. James’ Care Co-ordinator told the inquest that he first became aware of James’ arrest in November while James was in police custody following the execution of that warrant at his home address. 

The arrest warrant was executed on 20 November 2016. PC Walker told the inquest that in planning for James’ arrest, although he was aware that James had a specific marker for schizophrenia on the police records management system, he didn’t think the execution of the warrant required any different planning steps from any other arrest. Although police records contained details of the community mental health team that provided James’ care, there was no contact between the police and the Community Mental Health team preceding James’ arrest on 20 November 2016.

On 20 November 2016, police attended James’ home to execute an arrest warrant. James refused to allow officers entry into his home, and the arrest was effected by forced entry. During the arrest, James received a baton strike to the head and taser was used three times against him. As a result, James sustained a head injury and taser barb wounds which required treatment at A&E.

On 2 December 2016, James submitted an online complaint to the then IPCC regarding the force used to effect his arrest on the 20 November. The inquest also heard that on the same day, messages from James’ Facebook account indicated to his friends that he was not returning to college which up until that point, had been an important part of his life. 

Community mental health became aware of James’ arrest on 21 November 2016, but did not obtain any further information about the circumstances of the alleged offence or whether James had been collecting his medication, nor did they make contact with any of James’ community ties or his family.

On 6 December 2016, Police attended James’ address again in order to arrest him for breach of bail, but found James in his bed clearly deceased. In James’ kitchen, officers found a number of empty clozapine blister packs which, when full, would have contained 140 tablets.

The family believe that, between July and December, James’ mental health was deteriorating because he was withdrawing from social contact, although the family did not know this at the time, since they heard nothing from the police, the Community Mental Health Team or Conwy Social Services Access Team until after James’ death.

The family are also concerned about the absence of communication between the services providing James’ care, since his Care Coordinator and responsible clinician did not find out about James’ death until the afternoon of 9 December, by chance when the Patient Administration System was consulted.

At Post Mortem, the pathologist was unable to determine a pathological cause of death. Six foil discs from the blister packs were found in James’ stomach and Toxicology confirmed the presence of clozapine in James’ liver, however the amount was not determined. Based on the evidence, the Coroner was unable to determine a medical cause of death.

James' family said:

We look forward to attending court again on 2 May to address a Prevention of Future Deaths report. If any life can be saved in the future, this will be the best possible outcome of James’ inquest.

Alice Stevens, Solicitor at Broudie Jackson Canter said:

James’ family have finally been able to hear all of the evidence relating to his death at this inquest after waiting almost three years to get to this stage.  There have been multiple issues in the case, with Legal Aid Funding initially being refused and a new Coroner eventually hearing the case.  Despite these hurdles, the family have fought tirelessly for a full and fearless inquest into James’ death.  I hope that in due course a Prevention of Future Deaths Report will be issued by the Coroner reflecting the clear ongoing issues within multiple Public Authorities raised during the inquest.             

Anita Sharma, Senior Caseworker at INQUEST said:

James’ family have fought tirelessly for funding and an Article 2 inquest to uncover systemic failures.  Without the support of specialist legal advice they would have been left in the dark.  The evidence heard at the inquest highlights the poor communication within and across services that should have protected James, a man known to have mental ill health. It is hoped the Coroner will take this learning forward and issue a Prevention of Future Deaths report so no other person dies in these tragic circumstances.

The family have been supported by Anita Sharma and the charity INQUEST throughout the inquest process.  The family is represented by INQUEST Lawyers Group members Alice Stevens and Lauren Bailey of Broudie Jackson Canter Solicitors and Anna Morris of Garden Court North Chambers.