James Tyson was 46 when he tragically died on 6 October 2016.

James’ family welcome the conclusion of the inquest jury who today returned a critical narrative conclusion which stated that James died as a result of inflicting multiple incised wounds to himself on 6 October 2016. Based on the evidence, the jury concluded that James’ intention when harming himself was unclear. After hearing evidence over 4 days and deliberating for 2 days at Liverpool Coroner’s Court, they concluded the following factors contributed to his death:

1. Prescribed medication did not adequately reduce his anxiety
2. His symptoms of tinnitus became distressing
3. The pressure of the possible termination of his tenancy
4. James’ personal view that he was being pushed too quickly, also the fact that his mum was concerned that his mental health was deteriorating
5. Failure to collate individual parties’ concerns and observations and to act on all these concerns
6. James participated in the strategy to improve his mental health. The consequences of which caused increased anxiety levels.

James was a beloved son, brother and friend. He was cheerful, mischievous, intelligent and easy to get along with and the inquest was told repeatedly by witnesses about his good character and how well liked he was. James was a joiner and was well respected by all of his colleagues. He became unwell with schizophrenia in 1991 and remained ill until his death. He also suffered from severe anxiety and depression.

James spent much time in the community with his illness and also spent periods in hospital. He was under the care of Mersey Care NHS Foundation Trust throughout his illness. James was admitted to Broad Oak Unit in August 2015 after an incident involving serious self harm.  He was moved to Rathbone Rehabilitation Unit in Liverpool in December 2016 where he remained until his death.

Initially whilst at Rathbone, the inquest heard evidence that James improved greatly and managed to lose a significant amount of weight. James attended courses in the unit and his family visited him regularly.

James was prescribed the antipsychotic, Clozapine to treat his symptoms of schizophrenia. After losing weight and complaining of physical side effects of this medication, a doctor decided to reduce the amount of Clozapine he was prescribed in January 2016. He was also placed on an antidepressant to assist with his severe anxiety. Over next 6 months, James’ Clozapine continued to be reduced. In July 2016 he began to have psychotic symptoms and suicidal thoughts again, at which point his Clozapine dosage was increased slightly. The jury noted in their conclusion that they had heard evidence that the medication James was on was inadequate to manage his levels of anxiety. Mersey Care’s internal report was also critical of the reduction and a failure by James’ medical team to properly consider its impact on his anxiety and risk of suicide.

The inquest heard evidence that various members of staff were working with James to try and prepare him to live in the community. It was James’ ultimate goal to be able to live in his own flat. In August 2016, James was moved to a bedsit within Rathbone where he was able to cook his own meals using his own kitchen. An Occupational Therapist and Psychologist worked with James to assist in his transition to the community. However, James became more anxious at the thought of having to go back to the community so quickly and told staff that he was being “pushed too fast”. He began to deteriorate and was seen by staff members and family members rocking in the corner of his room. He had serious panic attacks sometimes lasting hours and was given PRN medication to assist in calming him down. He began hearing ringing in his ears, the cause of which was not ascertained.

In the weeks before his death, James’ mother repeatedly raised concerns with his psychologist and staff members that he was being pushed too fast. She told the inquest that she was concerned that the staff were not picking up on the signs that James was not doing well and that she was “brushed off” by them when raising her concerns. 

The jury noted in their conclusion that they heard evidence that an increased level of anxiety would have increased the risk of him having suicidal thoughts and of acts of self-harm.  James’ clinical pathways notes (CPN) clearly stated in a section headed “Shared Summary of Potential for Suicide and Self Harm” clearly stated this. Despite the concerns raised by James’ mother, James and his CPN notes, his observation levels remained at hourly intervals. Witness from the Trust told the inquest that they had no concerns that James was at risk of suicide and self harm. 

On the morning of 6 October 2016 at approximately 9.00am, a member of staff went to check on James for his hourly observation. James was found unresponsive in his room having injured himself. An ambulance was called but James was pronounced dead at 9.41am.

James’ family said:

We are devastated by James’ death. James was a happy and cheerful man and we loved him so much. We trusted Mersey Care and believed that he would get better if he was in their care. Instead, they let James down by failing to listen to him when he told them how much he was struggling. They did not listen to us when we warned them of his regression.  We are heartbroken.

We are grateful to the jury for their conclusion. We are concerned that James’ death is now one of many in Mersey Care and that not enough is being done to prevent other people from dying in their care. We hope that these findings will be taken seriously in order to prevent further tragic deaths. We cannot thank our legal team enough for their work and support, in particular the work Tom, Alice, Mira, Beth and INQUEST have put in.

Alice Stevens, of Broudie Jackson Canter and representing James’ family, said:

James’ death is yet another tragic and unnecessary death of a vulnerable man under the care of Mersey Care. The jury’s conclusion is clear that there were considerable failures in James’ care. Time and time again failures of this Trust have been recorded by inquest juries and James’ inquest is no different. James’ family have carried themselves with great dignity throughout a difficult inquest process. We urge Mersey Care to take the jury’s findings seriously and continue to implement changes in order to prevent deaths like James’ from happening in the future.

INQUEST has been working with the family of James Tyson since 2016. The family is represented by Broudie Jackson Canter Solicitors and Garden Court Chambers.