An inquest jury have concluded that a number of failings by a mental health trust contributed to the death of Lee Arnold, an in-patient at Peasley Cross Hospital in St Helens, Merseyside.

Lee, described by his family as “a bright and kind-hearted man” with a great love for motorbikes, died on 18 July 2017 at the age of 42. His inquest was held at Sefton, St Helens and Knowsley Coroner’s Court between 16-24 February 2022 before HM Assistant Coroner Johanna Thompson.

Lee had a diagnosis of paranoid schizophrenia and was detained under Section 3 of the Mental Health Act at the time of his death. He had been known to mental health services since 2000 and received care both in the community and as an in-patient.

In May 2017, Lee’s older brother Mark became concerned that Lee had stopped taking his medication and his mental health was declining. Following a mental health assessment, Lee was admitted to Taylor Ward at Peasley Cross Hospital under Section 2 of the Mental Health Act on 20 May 2017. 

After only a few days in hospital, Lee was granted escorted leave and this quickly progressed to unescorted leave, without significant inquiry into his psychotic symptoms and despite him not being settled on his medication.

On the morning of 17 July 2017, Lee went on unescorted leave. He was due to return at 4pm, but it was not until a head-count was conducted at 9pm that staff realised that Lee was still not back. Staff called Lee and requested that he return to the ward. The police were then notified. At approximately 10.20pm, Lee returned of his own volition. A breathalyser test showed that he was just over the drink driving limit and as a result, a decision was made to omit his night-time dose of medication.

On two occasions that night, Lee presented to night staff with signs of distress and expressed delusional ideas. He refused a 1-to-1 session with a mental health nurse and declined an offer of medication. Despite the clear increase in his level of risk, he remained on hourly observations. The observation check which was due to take place at 7am did not occur. At 7.25am, staff on the morning shift noticed that the window to Lee’s bedroom was blocked. On opening the door, Lee was found unresponsive.

The inquest heard four days of evidence from staff at North West Boroughs Healthcare NHS Foundation Trust who were involved in Lee’s care in the community and on Taylor Ward. After several hours of deliberation, the jury returned a narrative conclusion, stating that while they were unable to determine Lee’s intentions, they believed his death was associated with his mental health illness.

In a document annexed to the Record of Inquest, the jury adopted admissions which had been made by the Trust in respect of failings which contributed to Lee’s death, including not noticing that Lee had not returned from leave, failing to conduct a risk assessment upon his return and not increasing his level of observations after he presented distressed. These reflected the critical findings of a report prepared by Professor Shaw, a forensic psychiatrist, whom the Coroner instructed to comment on the care afforded to Lee.

Commenting on the inquest conclusion, the family’s solicitor Lucie Boase of Broudie Jackson Canter said:

Following Lee’s death in July 2017, North West Boroughs Trust implemented marked changes to their practices in the hope of preventing another death like Lee’s. While these are to be welcomed, it is regrettable that it took this desperately sad incident for serious shortcomings to be identified and addressed. It is right that the inquest jury adopted the failings admitted by the Trust and that these appear in Lee’s Record of Inquest as a matter of undisputed public record.”

Lee’s brother Mark said:

Lee was my brother, best friend and nobody knew me like him. His passing left a hole in my heart that will never be filled. He supported me as much as I did him and I miss him every single day. I really hope that nobody has to endure this feeling of loss in the future.”

Get in touch with Lucie Boase.