Jury at the Inquest into the death of Astonn Mitchell-Male returns critical conclusions against GMP, Pennine Care and the Richmond Fellowship

Before HM Area Coroner Mrs Lisa Hashmi
Greater Manchester (North) Coroner’s Court

Astonn Mitchell-Male was 31 when he was tragically found dead on 1 November 2016. The family of Astonn welcome the conclusion of an inquest jury who yesterday returned a critical narrative conclusion.

The Jury found that:

“Care provided to Astonn by Pennine Care NHS Foundation Trust was lacking in the supervision of compliance with his medication and all round risk assessment” and that “this was a leading contributor in the deterioration of Astonn’s mental health”.

The Richmond Fellowship, who were responsible for housing Astonn, were found to have “provided inadequate out of hours provision for support to mitigate any risk to Astonn at his residence”.

The jury also criticised Greater Manchester Police (GMP) who they say provided insufficient background checks and did not follow their procedures. They criticised the police officers attending Astonn’s flat on 31 October 2016 who they said “made insufficient attempts to establish relevant background checks” and “took inadequate steps to assess AMM welfare and subsequently assess the risk of harm to himself”.

Astonn died as a result of multiple self-inflicted stab and incised wounds after being found in his flat on the morning of 1 November 2016. His mother described him as family orientated and a very good son who she was close to. He was a shy, sensitive man and a keen footballer.

Astonn was diagnosed with schizophrenia in his late 20s after becoming unwell and being admitted to hospital. The jury heard evidence that Astonn was placed on medication to manage his symptoms, however he was not always compliant with this medication, something which his mother was extremely concerned about and repeatedly told those responsible for his care.

In February 2016, Astonn moved to supported accommodation under the Richmond Fellowship’s care. The jury heard evidence that they provided support workers who were required to observe residents and communicate concerns with mental health teams. Astonn was under the care of Pennine NHS Foundation Trust’s Community Mental Health Team.

In the months before his death, Astonn became increasingly unwell and was detained under s.136 of the Mental Health Act just over a month before his death, after he was found agitated and shouting in the street with no clothes on. A few days after this he was sectioned again, however he was released from hospital after less than three weeks. His mother gave evidence that Astonn spent much of his time on leave in her house and she was not invited to ward round meetings or invited to give her opinion as to Astonn’s care or treatment.

When released from hospital, Astonn returned to the Richmond Fellowship. In the time between his release from hospital on 14 October and his death on 31 October, he was not assessed in a meaningful way by his CMHT Care Coordinator, whose only physical contact with Astonn after his discharge in this time was seeing him on his doorstep on one occasion for a few minutes, during which he noted Astonn seemed to be unkempt and that it was difficult to fully assess him.

In the evening of 31 October 2016, Astonn’s neighbour called the on call support worker in Richmond Fellowship after hearing screaming coming from Astonn’s flat. The support worker called the police and informed them of the neighbour’s concerns and of Astonn’s mental health issues, he himself did not attend the flat, call Astonn’s Care Coordinator or his mother.
The jury heard evidence that this call was not allocated in the time required by GMP Policy and police arrived more than two hours after the initial call to them. On arrival at the Richmond Fellowship complex, Police tried to gain access by ringing other resident’s buzzers to allow them access but no one answered. There was a key safe box with an access code on site, but neither the Police nor the Richmond Fellowship thought to investigate how the Police could gain access to Astonn’s flat via this method. The Police did not try to contact Astonn or anyone else and therefore made no checks to Astonn’s welfare despite being aware that the initial call was made to them due to a concern that he was having an “episode”. Officers in attendance were aware that Astonn had previously had a psychotic episode at that address that had required the attendance of police officers to detain him.

The police stood down the ambulance that had been called to accompany them and left the property. One of the officers who gave evidence at the inquest accepted that she should have made more attempts to enter the property and check on Astonn’s welfare.

The next morning, Astonn’s mother woke up to a voicemail on her phone from Astonn which was left at 8.52pm the previous night. This harrowing call was played to the jury in full and in it Astonn can be heard screaming and threatening to kill himself. She called the police and they attended Astonn’s flat with her where they found the door to his flat unlocked. Astonn was found dead in his living room. He had inflicted in excess of 30 stab wounds upon himself.

Astonn’s Mother said:

My son displayed great strength towards the end of his life having battled with mental illness for many years.
He had the support of a loving and caring family. As a family; we had a right to expect those responsible for his care when in hospital and for ensuring that he was safe whilst in the community to have done more to facilitate his wellbeing. Particularly in light of the depth of information provided to them. Sadly that did not happen and as a consequence my son lost his life in the most tragic of circumstances.

This has been a multi-agency failure and it has been difficult to digest the extent of the failings that this Inquest process has quite rightly identified on the part of the agencies involved. In particular - those of the Trust’s Care Co-ordinator whose actions were criticised both by the jury and through the Coroner’s Regulation 28 report. May they hold their heads in shame!

Alice Stevens, representing the family said:

Astonn’s family carried themselves with incredible dignity through a difficult inquest process. Astonn’s death is a tragedy for this family and all those who loved him. He was an extremely unwell man who was not afforded the care he needed and deserved. This jury have rightly criticised those responsible for his care for their actions in the lead up to his death and
it is positive that the Coroner has also recognised Pennine Trust’s failures through her Regulation 28 report. I hope that Pennine Trust, the Richmond Fellowship and Greater Manchester Police look very carefully at the findings of this inquest and make necessary changes to their practices to ensure that no further deaths occur under their care.

The family have been supported by INQUEST since Astonn’s death in 2016. The family is represented by INQUEST Lawyers Group members Alice Stevens and Leanne Devine of Broudie Jackson Canter Solicitors and Anna Morris from Garden Court North Chambers.