Sarah Hemingway of the Garden Court Inquests & Inquiries Team represents Danny’s family, instructed by Keiu Kikas, Natalie Acheampong-Sarpong and Mollie Eglesfield of GT Stewart Solicitors.
Danny Jay Anderson, aged 35, died on 30 March 2023 by suicide contributed to by neglect, just two months after being discharged from the care of Essex Partnership University NHS Foundation Trust (‘the Trust’).
HM Coroner Nadia Persaud determined that Danny died by suicide, contributed to by the neglect of the Trust. The Inquest exposed a number of failures on behalf of the Trust, including failures to correctly diagnose Danny’s mental health condition, failing to assess him for supported accommodation, failing to adequately risk assess Danny and implement a comprehensive safety plan post-discharge, and failing to provide him with adequate care after discharging him from the Trust’s mental health services, despite significant concerning signs of Danny’s deteriorating mental health.
Danny’s family remember him as an intelligent, passionate and driven young man. He will be missed by all his family.
Factual background:
Danny struggled with his mental health from a young age. He had long history of self-harm and suicidal ideations. Danny had been hospitalised several times due to previous attempts to his life.
In June 2022, Danny was sectioned in a hospital managed by the Trust, who had accepted responsibility to manage his risk and look after him. During his admission in the hospital, Danny continuously presented with psychotic symptoms, yet it was noted in his records that he was presenting as stable and would not require supported accommodation.
The Coroner heard evidence of Danny’s fluctuating mental health diagnosis, whilst under the care of the Trust between June and December 2022. Danny was eventually diagnosed with complex PTSD. This differed from the opinion of an independent psychiatric expert instructed by the Coroner, whose view was that Danny was likely to have been suffering from paranoid schizophrenia.
The Trust did not conduct a comprehensive risk assessment prior to discharging Danny from hospital, and no concrete safety plan was implemented to support Danny’s transition back into the community. Information was not communicated to the local authority housing team, resulting in Danny being placed in accommodation which was not adequate for his needs.
In the last two months of Danny’s life, there were occasions where Danny suggested to the community mental health team, he would not take his medication. Despite this being a marked risk of deterioration, Danny was not risk-assessed again, and no
proactive steps were taken by the Trust to safeguard Danny. He was never visited by any mental health service under the Trust after being discharged.
Danny’s GP was never informed that he had been discharged from the hospital. A discharge summary sent to Danny’s GP on 30 January 2023 seemed to have been copied and pasted, using pronouns such as ‘her’ in his notes.
On 18 January 2023, Danny was discharged from the community mental health team. A letter was sent to Danny, stating he was discharged from Basildon Recovery and Wellbeing Team as of 3 February 2023. No further effort was made by the Trust to fulfil their statutory duties of providing Danny with aftercare in the community, despite the obvious signs of decline in Danny’s mental health. Danny died by suicide, contributed to by neglect, on 30 March 2023.
Family comment: “We are deeply saddened and devastated that we lost our son to such tragic circumstances, that were found avoidable by the Coroner if the correct care and procedures were implemented by the Trust and the care team.
We will remember Danny as an intelligent, outgoing, confident and driven individual, but we’ll also never forget the demons that haunted him for so many years, as they do for many others who live with mental health conditions.
During the inquest we found that members of the Trust showed little to no remorse in the neglect as described by the Coroner, with wholly inadequate measures that have been put in place to prevent similar incidents happening again.
We urge the Trust to take note of this case and the findings in order to take necessary steps and make real and meaningful changes to avoid any other family suffering like we have. RIP Danny Jay Anderson, 01.01.1988 to 30.03.2023.”
Other Interested Persons represented include Essex Partnership NHS Trust and Basildon Borough Council.
