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The East London NHS Foundation Trust missed a vital opportunity to prevent a suicide, a coroner has ruled. The trust has accepted liability for the death and Duncan Lewis’ Action Against Public Authorities solicitor Courtney Smith, who successfully represented the family in the inquest into the death of their son, is now negotiating a damages claim.

The deceased took his own life following a failure by East London NHS Foundation Trust’s Crisis Team to accept a referral to its service and to make an urgent assessment.

Submissions were made on behalf of the family in relation to Article 2 of the European Convention on Human Rights (ECHR). HM Coroner accepted those submissions and found that Article 2 was engaged, meaning and that the scope of the inquest was widened to allow consideration of ‘in what circumstances’ the death had occurred.

In summary, HM Coroner considered there was an arguable breach of both the operational and procedural obligations which Article 2 of the ECHR places upon the state to protect those under its care and that an enhanced investigation into the death was therefore required.

In evidence at the inquest, the Crisis Team’s Nurse Practitioner accepted having ‘erroneously omitted’ to document a telephone conversation with Bedfordshire Wellbeing Service, during which a referral to the Crisis Team was made. They suggested they were not aware the Bedfordshire Wellbeing Service was attempting to make a referral and understood the call to be for advice only. They also said they were not aware the deceased was not registered with a GP, where he was redirected for further support.

It was also established that the Bedfordshire Wellbeing Service was unaware of a recent service change which would have enabled the deceased to self-refer to the Crisis Team and so information regarding this was not passed to him.

Within their conclusions, HM Coroner highlighted a missed opportunity to assess the deceased at the earliest opportunity, which could reasonably have prevented their death. It was established in evidence that had the crisis team accepted the referral by Bedfordshire Wellbeing Service, the deceased would have been given a same day urgent assessment. HM Coroner took the view that an urgent same day assessment would have provided a substantial chance of a different outcome for the deceased.

Following the conclusion of the inquest, a claim was issued on behalf of the family for breach of Article 2 of the ECHR, negligence and for damages under the Law Reform (Miscellaneous Provisions) Act 1934 and the Fatal Accidents Act 1976 (FAA). Damages are claimed on behalf of the family. The Trust has accepted liability for the death of the deceased, subject to causation, and made a Part 36 offer to settle. Negotiations are currently ongoing and Courtney hopes to settle this claim on behalf of the family for a substantial sum.


Courtney Smith is a solicitor and supervisor in Duncan Lewis’ Actions Against Public Authorities Department, who specialises in inquests and claims against public authorities. She is a member of the Police Action Lawyers’ Group, and holds public authorities to account when they abuse their powers or fail to observe their professional obligations.

If you or a family member are affected by any of the issues raised by this article, please contact her for advice via email at courtneys@duncanlewis.com or telephone on 020 7923 8416.