Missed Opportunity Prior to Death of Journalist & Campaigner Dan Kay
The inquest into the death of journalist and Hillsborough campaigner Dan Kay concluded on 7 November at Gerard Majella Courthouse in Liverpool. The Coroner concluded that Article 2 was engaged in the inquest and reached a critical conclusion. Dan’s family were represented by Cian Murphy, instructed by Leanne Devine of Leigh Day.
On 1 May 2023 Dan was brought by ambulance to Royal Liverpool University Hospital after he had made two attempts on his own life in a three day period. He had a history of poor mental health, and in the months prior to his death, a change in employment, move to a new home, and his adoption and ultimate death of a rescue dog, all contributed to a severe deterioration in his mental state. Despite Dan’s presentation he was discharged from hospital into the care of the Crisis Resolution Home Treatment Team of Mersey Care NHS Foundation Trust.
After days of evidence, and written and oral submissions on behalf of the family and the Trust, the Coroner concluded that the State’s enhanced investigation obligation was engaged because there was an arguable breach of the operational duty to protect Dan’s right to life. There was a real and immediate risk to Dan’s life, and although he was not an inpatient, there had been an assumption of responsibility for his care. The Coroner took into account Dan’s exceptional risk and his particular vulnerability.
The Coroner also took into account that, for Dan, home treatment was seen as an alternative to a hospital stay because he was going to be visited every day. He heard evidence of visits to Dan on 2, 3, 4, and 5 May.
However, after the latter visit, there was an informal assessment of a diminution of risk, not recorded or discussed with any other staff member. As a result a decision was taken that Dan would not be visited on 6 May but would instead have telephone contact. A visit intended for 7 May was cancelled and rescheduled for 8 May.
On 7 May Dan was found deceased on the railway line near his home.
The Coroner concluded that “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.”
During the inquest, the coroner made inquiries with Liverpool City Council, in relation to Dan’s ability to access the railway, despite it being fenced off. These inquiries led to the immediate removal of street furniture near the railway fence.
Mersey Care NHS Foundation Trust told the Court that various changes have been made since Dan’s death: in relation to induction processes, training, use of templates for record keeping, the use of clinical leads, and processes when patients cancel arranged visits.
Dan’s family, led by cousin Amos Waldman, and uncle Steven Waldman, as well as Dan’s friends and newspaper colleagues, have established the Dan Kay Foundation in his memory. The Foundation aims to tackle stigma around mental health.
The inquest has been the subject of daily reporting by the BBC (here, here, and here); and by the Liverpool Echo (here, here, here, and here) as well as other outlets.
