Mental Health Failures Leading to Death by Suicide

The Claimant was the family of a patient who had been a devoted parent, partner and business owner, described by those close to him as caring, loyal and deeply committed to his family and friends. He lived a stable and settled life, with strong relationships and an active role in family life.

Several years prior to his death, the patient’s young child was diagnosed with cancer. During the child’s chemotherapy treatment, the patient struggled emotionally. Although his child later received the all-clear, the psychological impact of this period led to anxiety, guilt and depression.

He sought medical support and was prescribed antidepressant medication. While there was an initial improvement, his mental health later deteriorated and he began experiencing a manic episode. Changes in behaviour became increasingly apparent, including impulsivity, uncharacteristic social behaviour and sudden, unrealistic life plans.

Concerned for his safety, family members encouraged him to attend his GP. Although the GP acknowledged the behaviour was unusual, no urgent action was taken. Following a request for a second opinion, a psychiatric assessment confirmed that the patient was experiencing a manic episode and should be sectioned under the Mental Health Act. Due to a lack of available hospital beds, he was instead referred to A&E.

While awaiting admission, the patient absconded, experiencing paranoid beliefs. He was later located in a distressed state and formally sectioned, diagnosed with bipolar disorder, and admitted to hospital for four weeks.

Following discharge, the patient expressed suicidal thoughts to his family. These concerns were raised with mental health services but were not treated as requiring urgent intervention. Despite escalating warning signs, including withdrawal from daily life, avoidance of family contact and clear symptoms of severe depression, safeguards were not put in place.

Crisis team involvement was limited. Initial assessments concluded that he appeared stable, and subsequent follow-ups were conducted by telephone at his request. No face-to-face assessments or enhanced monitoring were arranged, despite repeated concerns raised by family members.

Three days after the last assessment, the patient took his own life. The impact on the family was devastating, resulting in bereavement, trauma and the transition to single parenthood.

Following the death, the Trust carried out an internal investigation. Although issues were identified, they were characterised as minor oversights. The family felt the seriousness of the failures had not been fully acknowledged.

The family instructed Forbes Solicitors to investigate whether negligence had occurred. The motivation for the claim was not financial gain, but to obtain answers, accountability and reassurance for their child that the death was the result of a mental health crisis that had not been properly managed.

Independent expert evidence confirmed that with appropriate assessment, monitoring and intervention, the death was likely preventable. The claim focused on failures in risk assessment, safeguarding and continuity of care following discharge.

The case concluded with an admission of failings by the Trust and a formal apology to the family. Financial compensation was awarded, reflecting the profound impact of the death, including emotional loss, practical consequences and changes to working arrangements following the transition to single parenthood.

While the legal process was extremely challenging, the family felt the outcome provided validation, a sense of closure and reassurance that lessons had been learned to help protect others in similar circumstances.

This case highlights the critical importance of robust mental health risk assessment, particularly following discharge from inpatient care and where family members raise repeated safeguarding concerns.

Expressions of suicidal ideation, behavioural change and deterioration in mental health must be responded to with appropriate urgency. Where systems fail, families are entitled to answers, accountability and meaningful change.