A jury at Liverpool Coroner’s Court have found failings contributed to the tragic death of Michael Cooke on 16th August 2019. Michael was 30 years old.

At the time of his death Michael was a patient detained under Section 3 of the Mental Health Act 1983 at Springview Hospital, which is run by Cheshire and Wirral Partnership NHS Trust (‘CWP’).

Prior to being detained in hospital Michael had been diagnosed with Autistic Spectrum Disorder (ASD) in a detailed 24-page report, as well as Pathological Demand Avoidance (PDA). He had been under the care of the Early Intervention Team (EIT) in the community since 2017, which is also run by CWP, but had struggled to receive the necessary care to meet his needs. Following his diagnosis of ASD in April 2019, this was not recorded properly on the CWP electronic records system, and although the inpatient team in July 2019 had access to the full report, this was never read by Michael’s inpatient clinicians.

On 24th July 2019 Michael was admitted to Springview Hospital under section 3 after it was assessed that he posed a risk to his own health and safety.

On 8th August 2019 two nurses decided that he could be granted unaccompanied leave within the hospital’s grounds. Trust policy required a clinical risk assessment to be done in advance of this decision. There is no documentation that this was done, as well as there being no documented risk assessment since his admission. In addition, his care plan was not updated following this change.

Michael was allowed out unaccompanied into the grounds on several occasions over the following days. During the morning of 16th August 2019 he told staff that he was feeling anxious but after he was given medication he was allowed on leave in the hospital grounds 5 minutes later. Just 15 minutes later he sadly came by his death after leaving the hospital grounds.

In the days leading up to his death, Michael handed a box containing some sweets, beads, and a note to reception to be passed to a family friend. The receptionist did not think to pass on this note to clinical staff, and instead the note had to be retrieved from the confidential waste following Michael’s death. Having seen the note following his death Michael’s family consider the content highlights how unwell he was at the time.

The inquest was held before HM Senior Coroner André Rebello sitting with a jury over five days between 20th and 24th July at the Liverpool Coroner’s Court.

The jury returned a conclusion that Michael died by way of suicide whilst suffering from poor mental health about which he had no insight., The jury returned findings critical of the care and treatment provided by the Trust, and identifying missed opportunities to prevent his death including:

• In relation to the note which Michael handed to reception in the days before his death: “This was not handed to the ward and is a failure which contributed in more than a minimal way to Michael’s death, the note could have prompted a review with Michael. This was a missed opportunity.”
• Whilst the Trust alleged that a risk assessment was conducted on 8th August 2019 concluding Michael could have unaccompanied grounds leave this was not documented within his medical records or elsewhere. The jury found that this was a failing, and it was not appropriate for Michael to have grounds leave between 8th August 2019 until his death.
• “It is a serious failure that the ASD diagnosis was not properly recorded. It is a serious failure that the staff did not read [the ASD Report]. This contributed in more than a minimal way to Michael’s death. It is unsatisfactory that a follow-up referral to ‘Autism Together’ was not made after the [ASD Report].”
•   It is unsatisfactory that there was no psychologist available during the period that Michael was an inpatient 
• “The document and process used for patients leaving the ward on grounds leave is inadequate.”
• The morning of his death Michael was reported to be agitated and asked to see his Responsible Clinician, who was unavailable at the time. The jury found “This was a missed opportunity to review Michael before he left the ward at 10:35am.”

Michael’s parents are incredibly grateful to the jury for treating Michael’s inquest with such care and sensitivity, and for their attention to the evidence. They say:

We want to thank each of the jurors; their findings bring recognition and accountability for what happened. These failings are things we as Michael’s parents have known all along, but for years the Trust have been making us feel like we were just overprotective parents, and that nothing could have been any different. But we know Michael’s death didn’t have to happen. So many times during this long inquest process we asked ourselves if it was even worth it, and now we know that it was.

Our wish has always been for no other family to go through what we have. It’s not about blame, but when there are systems in place like this that aren’t keeping patients safe, there needs to be a discussion about how we can improve them. We hope by speaking out we can make more people in the community aware of these issues and prevent what happened with Michael happening again.

We would also like to thank our Family Liaison Officer Mike Almond who has supported us throughout this entire difficult process and has been with us since 16th August 2019.

The parents of Michael remain concerned about the Trust’s policy surrounding grounds leave and the adequacy of safety measures at the hospital for those detained there.  There are no perimeter fences around the general psychiatric unit to ensure that patients stay within the hospital grounds when they are granted unaccompanied grounds leave.  Although sign in and sign out is required, the Trust’s policy provides no specific guidance on the nature of the risk assessment which should take place prior to granting unaccompanied grounds leave and crucially the policy is silent on considering the risk of a patient absconding.

Michael’s parents remember him as kind, loving, happy, sincere, loyal, genuine, humble, caring, affectionate, and sentimental. They say he was the embodiment of what was good and right in the world. Michael was a very talented musician with a passion for playing the guitar as well as writing his own music. His favourite past times were going to open-mic nights and performing in different musical bands. Michael developed a close group of friends through this. He was patient and thoughtful, often taking time to teach friends the guitar. He loved challenges and was looking forward to his future and plans to travel.

Clair Hilder of Broudie Jackson Canter, who represents Michael’s family, says:

Michael had been detained in hospital for his own safety and so he could receive treatment. Going on leave both within hospital grounds and within the community is an important part of ensuring that patients are ready to be discharged but sadly in Michael’s case inappropriate precautions were taken to ensure he would be safe while on leave and he was able to leave the hospital.

Michael’s parents’ primary concern through the inquest process has been on making sure that lessons are learnt and we hope that the Jury’s criticisms which were not reflected within the Trust’s own internal investigation into the circumstances of Michael’s death result in further reflection by the Trust on their policies and procedures.

Michael’s parents are represented by Clair Hilder and Charlotte Halsted of Broudie Jackson Canter and Oliver Lewis from Doughty Street Chambers