Michael Kwiatkowski was just 27-years-old when he sadly died while being treated as an in-patient at Lynfield Mount Hospital in Bradford.

An inquest jury have concluded that a number of failings by staff at an NHS trust contributed to the death of Michael Kwiatkowski, an in-patient at Lynfield Mount Hospital in Bradford. 

Michael, who was described by his family as a “caring and loyal” young man who loved to laugh, died on February 10, 2019 at the age of 27. His inquest was heard at Bradford Coroner’s Court between May 15 – 17, 2023 before HM Assistant Coroner Ian Pears.  

Michael had suffered with psychotic symptoms for several years and was detained under Section 2 of the Mental Health Act 1983 at the time of his death. He had been known to mental health services since 2015 and received care both in the community and as an in-patient. 

From January 2018, Michael began to experience a significant deterioration in his mental health. On February 6, 2019, while living in assisted accommodation, Michael was found by a support worker to have self-harmed. Following treatment at the Accident and Emergency department at Bradford Royal Infirmary, Michael was admitted to Oakburn Ward at Lynfield Mount Hospital under Section 2 of the Mental Health Act. Staff were advised to commence Level 2, 1:1 observations on Michael.  

On February 7, Michael expressed suicidal ideation and thoughts of harming himself. He was seen to be responding to unseen stimuli. He was placed on Level 2, 2:1 observations by ward staff to ensure his safety. 

On the morning of February 8, Michael’s level of observations was reduced to hourly checks. Later that day, he was granted escorted leave from the ward, allowing him to visit Bradford city centre with two members of staff. Michael absconded and staff were unaware of his whereabouts for a period of five hours. During this time, a member of the public witnessed Michael attempting to throw himself into the path of oncoming traffic.  

Michael was eventually located and that evening, he was returned to the ward by the police. He was found to have items on his person including two razors and one razor blade. As he was demonstrating self-harming behaviour, Michael’s bed sheets and other items were removed from his bedspace.  

Michael was placed on Level 2 1:1 observations that evening. A healthcare support worker on the nightshift observed Michael suddenly run head-first into the wall of his room, and he was heard to express frustration that he was unable to kill himself.  

At 8am on February 9, Michael’s Level 2, 1:1 observations were discontinued. Michael requested his bedsheets be returned to him, and this was granted. That morning, Michael attempted to secrete a razorblade while shaving, and later a cutlery knife from the dining room, though these items were found and confiscated by staff.  

Despite his concerning behaviour, the level of observations that Michael was under was not increased. At 12.32pm Michael was found unresponsive in his bedroom by ward staff. CPR was commenced and he was subsequently taken to Bradford Royal Infirmary, where he sadly passed away on February 10, 2019.  

The inquest heard three days of evidence from staff at Bradford District Care NHS Foundation Trust (‘the Trust’) who were involved in Michael’s care in the community and on Oakburn Ward. After deliberation, the jury returned a short-form conclusion, stating that Michael was unable to form intention due to his mental illness, however his death was associated with his mental health illness. 

In a document annexed to the Record of Inquest, the jury adopted the admissions which had been made by the Trust prior to the inquest in respect of failings which contributed to Michael’s death, including that, on February 9, 2019:  

• Nursing staff missed opportunities to review and reassess Michael’s level of risk;  

• Michael should have remained on 1:1 observations; and  

• Michael’s bed sheets should not have been returned to him. 

Michael’s family were represented by Lucie Boase and Nicola Miller of Broudie Jackson Canter Solicitors and Jodie Blackstock of Garden Court Chambers. Commenting on the inquest conclusion, the family’s solicitor Lucie Boase said: 

“Following Michael’s death in February 2019, the Trust implemented marked changes to its policies and procedures in the hope of preventing another death like Michael’s. These changes are to be welcomed; however it is regrettable that it took Michael’s tragic death to prompt their implementation. It is right that the inquest jury adopted the failings admitted by the Trust and that these appear in Michael’s Record of Inquest as a matter of undisputed public record.” 

Michael’s younger sister Claire said: 

“As a family, we are relieved that after many years, Michael’s inquest has finally taken place and we can now begin to heal. We were devastated by Michael’s death and the circumstances in which he passed away. Michael was a kindhearted and loving son, brother, dad and friend. We miss him dearly, and only hope that changes can be made to the mental health system so that other families don’t have to go through the same pain that we have experienced.” 

Speak to a professional

There can be nothing worse than the sudden and unexpected death of a family member. At Broudie Jackson Canter, we have been concerned for many years about ensuring a full and proper investigation at an Inquest. We have developed a team of legal advisers who are able to help through this potentially traumatic process and we are able to advise in almost all Inquests and can guide you through the procedure.