“Mental health failed Daniel” – those were the words of a grieving mother as the Coroner finally concluded an inquest into the death of her son, more than 6 years after his body was discovered in woodland at Shanklin.
Senior Coroner Caroline Sumeray delivered an open conclusion following a hearing at the Isle of Wight Coroner’s Court yesterday (Wednesday) – held nearly 6-and-a-half years after the death of 32-year-old local man Daniel Dean.
The inquest heard how Daniel, who had a long and complex history of mental illness, was found dead in Sibden Copse, off Silver Trees Drive, in July 2019, as previously reported by Island Echo. He had been last seen alive 11 days before on 26th June.
Shockingly, 2 children playing near their home discovered his body in the undergrowth, just a day after their parents had noted a smell in the air. The body was badly decomposed and had to be identified through DNA analysis before being recovered by a specialist team.
In a 5-hour hearing, which had been delayed previously due to the amount of paperwork, the court heard that Daniel had battled serious mental health problems since his teenage years, including schizophrenia, delusional disorder and a paranoid personality disorder. He was admitted to hospital numerous times and sectioned under the Mental Health Act on several occasions.
Dr Alexis Bowers, Lead Consultant Psychiatrist for the Isle of Wight NHS Trust, described Daniel as an ‘extremely complex patient’ who struggled to engage with services and often lived rough. He said Daniel was a chronic cannabis user and had made repeated threats to harm himself and others.
The court heard that at times Daniel lived in his grandmother’s garden in Shanklin, urinating and defecating in bottles and boxes. Dr Bowers said he had repeatedly recommended that Daniel be sectioned, but those recommendations were not supported by other clinicians.
Daniel’s mother, Jane Cooke, told the inquest:
“Mental health failed Daniel all down the line. They left him to live in a shed like a dog”.
In December 2018 into January 2019, Daniel’s local authority case was closed, and his Section 117 aftercare – a joint duty of care between the NHS and local council for patients discharged from compulsory detention – was withdrawn. Dr Bowers admitted that, in hindsight, this was the wrong decision, saying the service at that time was under immense pressure and reliant on voluntary patient engagement.
6 months later, in early June 2019, Daniel attended A&E after telling staff he planned to overdose on insulin under Ryde Pier. He was then reported as a missing person on 10th June.
Later that month, he presented at Sevenacres mental health unit in a distressed state, wearing a winter hat and carrying a rucksack he refused to let go of. Despite concerns about his condition, he left the building before a formal Mental Health Act assessment could be completed, with staff having no legal power to detain him.
Then, in the early hours of 26th June 2019, the Isle of Wight Ambulance Service was called to a property in Leed Street, Sandown, following reports that Daniel had overdosed on insulin. Earlier that evening, he had been swimming in the sea around Sandown Pier and returned to the property agitated and confused.
Paramedics found Daniel conscious but unsettled. He was helped into the ambulance, where he told the crew that he had taken multiple doses of insulin. Before the vehicle set off to hospital, he became verbally aggressive and physical with staff. As a paramedic tried to calm him, a short struggle took place and both ended up on the floor of the ambulance.
As the interior lights automatically switched off, one of the crew opened the side door. At that moment, Daniel jumped out of the vehicle and ran back into the property. CCTV footage captured inside the ambulance saloon was played to the court. His landlady – who was also his lover – told emergency services that he had attempted to take knives from the kitchen but was stopped. Daniel then fled through the rear of the property.
A disciplinary hearing was later held in relation to the paramedic’s handling of the Leed Street incident and associated paperwork. The hearing resulted in a final written warning, which primarily related to record-keeping rather than the restraint used.
Later that same day, Daniel visited his grandmother, Patricia Dean, for the first time in 2 years. In a statement read to the court, she said she could tell he was at a ‘low point’. Patricia, who had cared for him through much of his childhood, said that Daniel’s mental health had long left her fearful. In the past, he had put a knife to her throat and chased children down the street with a machete.
Despite a detailed Police investigation and a Home Office forensic post-mortem, the cause of Daniel’s death could not be established. Further tests offered no explanation, leading to a formal cause of death recorded as ‘unascertained’.
Coroner Caroline Sumeray said Daniel had an extensive mental health history since childhood’ and was a challenging individual with complex needs.
She said:
“Decisions made – with the benefit of hindsight – were not good and denied the level of support that may have supported Daniel better.
“It is a truly tragic outcome”.
Mrs Sumeray said she had considered suicide, third-party involvement, and possible toxicity from berries found in Daniel’s pocket, but there was no evidence to support any of these possibilities, particularly due to the level of decomposition.
She recorded an Open Conclusion.
Six and a half years!! That is a truly disgusting wait for his poor family. Why oh why is Ms Sumeray still employed in this vital position when she has demonstrated that she is not up to the job.
In the old days if an employee was INCOMPETENT
in their job they would be given their P45.
Nowdays many emplyees are shirking from home on full
pay with regular pay increases
HOW TIMES HAVE CHANGED!
TBH all mental health services on the island are bad,psychiatrists get put on rotation,so you build trust with one,then they get moved on,chantry house has a session limit,so once they are done you are discharged back to your doctor with absolutely no support,half the time whoever you see doesnt read your notes,but discharging looks good on paper with the figures,not enough staff,and lots are leaving too,this poor guy was badly let down,as are others too,people mostly just get pills thrown at them now,waiting lists for therapy are years long,YEARS!
utter disgrace.
Sometimes people can’t be saved. I’ve had friends with mental health problems who have died by their own hand. If you dedicate yourself & try to keep them safe it isn’t possible. Even Mental Health teams cannot keep them safe if they are chaotic & unpredictable & they are determined to harm themselves. Unbelievably sad
So this man was let down by mental health services when he was alive and that has been appallingly compounded by being let down by the Coroner after his death. Six and a half years to record an open verdict. Ms Sumeray was the Conorner thoughout that period. Her record speaks for itself. Why is she being permitted to continue to draw between £130k and £145k a year for such poor performance? How she can, in all conscience, criticise mental health services against this background beggars belief.