Coroner’s Finding: NHS Team’s Lapse Possibly Contributed to Suicide

A coroner determined that the inability of a community mental health team to visit a Liverpool resident in the days following his attempt to end his life “possibly contributed” to his subsequent suicide. Dan Kay, aged 45, was discovered deceased on a railway line in Mossley Hill, within the city, on 7 May of the previous year. Following the conclusion of his inquest, Mr. Kay’s family, speaking outside the Gerard Majella Courthouse, stated that mental health professionals ought to have “tried harder” to ensure the safety of the journalist and Hillsborough campaigner. The inquest revealed that Mr. Kay had made two attempts to take his own life in the days preceding his death and had been admitted to hospital on 1 May. He was released from the hospital under the expectation that a specialist mental health team would provide him with daily visits. However, the inquest learned that on 5 May, this arrangement was reduced to phone calls and in-person visits every other day. This modification was enacted by a single staff member independently, without a formal risk assessment being conducted. It is understood that Mr. Kay subsequently contacted the team on 6 May to cancel a scheduled visit for the next day, an action that “should have raised alarm bells.” Assistant coroner Joseph Hart stated: “The reasons for his cancellation were not recorded or explored by the team under whose care Dan was. “The lack of a visit on the day of Dan’s death, in the absence of a visit in person the day before, could have had a real prospect of eventuating a different outcome. “The absence of formal consideration of the support needs possibly contributed to Dan’s death.” Mr. Hart informed the inquest that errors and overlooked chances by the Mersey Care NHS Foundation Trust constituted an “arguable breach” of Mr. Kay’s right to life, as protected by Article 2 of the European Convention on Human Rights. During the proceedings, Matthew Wigley, a member of the Mersey Care crisis team, testified that he was unaware of the reason for the cancellation of the 7 May visit, adding: “It was a huge mistake and I’m sorry.” Mr. Kay, who served as a journalist for the Liverpool Echo newspaper and advocated for families affected by the Hillsborough disaster, was characterized by his family as “warm, generous and caring.” His cousin, Amos Waldman, remarked after the inquest’s conclusion: “It was incredibly frustrating that these opportunities were missed. “Dan should have been here now.” Mr. Waldman expressed that it was “disappointing” that mental health professionals had not “tried harder to ensure Dan was safe.” He further stated: “We do feel that in the days before his death that Dan was let down by the team of people that was supposed to be there to give him the care and support he needed.” The inquest was informed that Dan had contended with mental health challenges for numerous years and had previously attempted to take his own life approximately 26 years prior. His mental well-being had markedly declined in the months leading up to his death, following the necessity to euthanize a rescue dog he had adopted due to its aggressive conduct. Leanne Devine, a partner at Leigh Day solicitors, who represented Mr. Kay’s family, commented after the proceedings: “It is a tragedy that someone who was so loved and respected in his personal and professional life, suffered so badly with poor mental health to the extent that it put his life at risk.”It is a greater tragedy that errors were made by the team tasked with keeping Dan safe in days of crisis in early May 2023.” A spokesperson for Mersey Care stated that the trust “prided itself on being a learning organisation.” They added: “Immediately after this incident we conducted a serious incident investigation and have updated our practices in line with recommendations from our internal review.” Audiences can access the finest content from BBC Radio Merseyside via Sounds and connect with BBC Merseyside on Facebook, X, and Instagram. Submissions for story ideas can also be sent to northwest.newsonline@bbc.co.uk. This material is copyrighted by BBC 2024, with all rights reserved. The BBC disclaims responsibility for the content found on external websites. Information regarding our policy on external linking is available for review.