Kirsty Brimelow QC acts as parents of Alex Turner call for lessons to be learned after inquest finds neglect contributed to their son's death

Kirsty Brimelow QC, instructed by Gus Silverman of Irwin Mitchell, represented the parents of Alex Turner, 24 years old when he was found dead on train tracks in Salford on 5 December 2019, having been hit by a train. He had lain on the train tracks. The inquest found that gross failings by the Greater Manchester Mental Health NHS Foundation Trust probably contributed to Alex’s death.

The hearing took place at the Coroner’s court in Bolton over 2 weeks.

Alex suffered a short period of mental illness and he and his parents turned to Greater Manchester Health NHS (GMMH) for help.  

The inquest was told Alex had been diagnosed with Emotionally Unstable Personality Disorder shortly after being admitted as a voluntary inpatient to North Manchester General Hospital’s Safire unit on 24 November following multiple suicide attempts. 

Alex told staff that he heard a voice in his head telling him to kill himself, and his father raised concerns that Alex had said he would jump in front of a train if he was discharged. Alex had repeatedly told staff that he would kill himself by jumping in front of a train, the hearing was told.

Despite this, the court heard that Alex was discharged without his family being told on 28 November and was sent in a taxi to the housing office in Chorley. He was very distressed and suicidal and the housing office immediately called an ambulance.  Alex then was admitted to the Eagleton Ward, Salford.

During his time on Eagleton Ward Alex reported suicidal thoughts. On 2 December, he told a consultant psychiatrist that he was hearing a voice in his head telling him “to go to the bridge” and that “he was going to throw himself into a train but his girlfriend asked him not to.” Later that day he told a nurse that he had “tried to jump off a bridge” but had been stopped by his girlfriend.

On 4 December he told a nurse that whilst on leave from the hospital with his girlfriend he had "tried to jump off the bridge on Stott Lane” which was yards from the unit “but couldn't climb over the railings". He also reported hearing the voice of the devil in his head.

According to medical records read out at the inquest, during a two hour appointment with a student nurse on 5 December Alex “reported that he had suicidal ideation and he wanted to be put on a section as he was unable to keep himself safe in the community”. The court heard he became distressed and shouted that the devil was telling him to kill himself. 

Later that day, during an appointment with a trainee psychologist, the court heard that Alex “expressed high levels of suicidality and stated that he was concerned about keeping himself safe if he was released from the ward”. The medical records stated that Alex “felt sure he would make a suicide attempt and he stated that he would go to the train tracks”. The trainee psychologist was very concerned and passed information to nurses responsible for Alex. However, no concerns about Alex were raised in nurses’ handover.

At around 8.30pm on 5 December Alex asked a member of nursing staff if he could leave the ward. The nurse told the court that he was not aware of how Alex had presented to the student nurse and trainee psychologist earlier in the day. He allowed Alex to leave the ward without an escort. 

The inquest heard that GMMH telephoned Greater Manchester Police (GMP) shortly after midnight on 6 December when Alex failed to return to the ward. Despite staff telling GMP that Alex had previously attempted to climb over the Stott Lane railway bridge it was not until 3.45am that GMP contacted British Transport Police (BTP).

A GMP search coordinator told the court that he expected that his colleagues would ask BTP to search the tracks within a 300 metre radius of the ward, which included the tracks under the Stott Lane bridge, but no such request was made. The court heard that the BTP control room breached its own procedures by failing to ask what GMP wanted them to do, before grading the call as low risk requiring no further action. Shortly after 5am Alex’s body was found on train tracks under the Stott Lane bridge. 

At the beginning of the inquest GMMH admitted that whilst Alex was on Eagleton Ward there had been failures to:

“Involve and engage Mr Turner’s father in risk formulation and risk management planning”

“Fully record information which was significant to risk assessment and management”

“Ensure that risk information gathered by [the trainee psychologist] was disseminated to staff on duty”

“Fully assess the escalating risk of Mr Turner harming himself on 5 and 6 December 2019”

“Formulate a robust risk management plan to address the escalating risk on 5 and 6 December 2019”

The inquest concluded:

Press release from Irwin Mitchell can be found here.    

Media coverage: Manchester Evening News, Lancashire Telegraph, Lancashire Post

If you have been affected by any of the issues raised here, please consider contacting the Samaritans who are available 24 hours a day, see here.