Coroner asks for detail of Trust changes after death

THE ‘untimely death’ of a vulnerable, mentally ill man after he was discharged from mental health services in Devon has prompted changes to be put in place.

Kieron O’Sullivan was found dead in the sea after going missing from his home in Dawlish on December 7, 2018. Just three days earlier, police had to intervene when the 64-year-old refused to move from a railway track, causing a train to stop in front of him.

A jury inquest at Torquay Town Hall heard how he had been taken to Torbay Hospital, but was discharged back to his sheltered housing flat in Dawlish on December 6, after a mental health assessment which included the input of three professionals.

The assessment concluded it was not appropriate for him to be detained, and that he should instead be supported by the crisis treatment team. On the day before he went missing, Mr O’Sullivan was discharged from the team into the care of his GP.

The inquest heard Mr O’Sullivan had written letters of complaint and was unhappy that he no longer had a care coordinator. The jury delivered an open conclusion into his death and stated that the removal of a Community Mental Health Team (CMHT) care coordinator was an influencing factor in his ‘untimely death’.

Senior coroner Ian Arrow has requested further information from adult mental health services provider Devon Partnership Trust about changes which have been implemented, following Mr O’Sullivan’s death, before reaching a decision.

During the inquest, evidence was heard that the Trust carried out a root cause analysis investigation report following the death, resulting in an action plan of learning being put in place.

Mr O’Sullivan was found dead by a commercial fisherman at sea off the coast of Portland three days after being reported missing on December 10, 2018. A post-mortem examination confirmed the cause of his death was drowning. The pathologist was unable to estimate how long he had been in the water for, or where he had entered the sea.

However, the inquest heard that, due to his mental health, he did not usually like to travel far from home and no sightings of Mr O’Sullivan, who had been dressed in his pyjamas and dressing gown, had been reported to police.

Evidence was heard from Detective Constable Kerri Hoskin-Cole, who confirmed he had lived alone at Brunel Court in Richmond Place since 2015, and had a long history of mental health conditions.

On January 7, 2018, emergency services were called after Mr O’Sullivan had been spotted in a road in his pyjamas in a ‘very distressed’ state.

Later that year, British Transport Police were called on December 4, 2018, to remove him from local train tracks and take him to hospital to be mentally assessed.

The jury concluded that, at the time of Mr O’Sullivan’s death, he was suffering from a mental health condition, but the jury said it was ‘unknown’ whether he took an action intending to end his own life immediately before his death.

Coroner Mr Arrow passed his condolences onto the family and friends of Mr O’Sullivan and said: “He was obviously well-liked and well-known in Dawlish. I am sure his loss has been severely felt by them all. I am so very sorry to have heard of his death.”