Trigger warning: mentions suicide
A team of lawyers working on a pro bono basis have supported a family through an inquest into the death of a young man. Karen approached Advocate on behalf of her partner, Sarah, whose son took his own life. Barristers Sunyana Sharma of 3PB and Markus Findlay of Doughty Street Chambers volunteered to assist at the inquest. Sunyana and Markus worked with a team of solicitors from Arnold & Porter through Advocate’s partner project Pro Bono Connect. The Arnold & Porter team included Adela Williams, Jacqueline Mulryne, Eleri Abreo, and Katya Farkas.
In August 2022, Sarah’s son, Ryan, took his own life. Prior to his death, Ryan suffered from serious mental health issues dating back to 2011 and had been diagnosed with severe depression in 2021 with psychotic features.
On 29th July 2022, Ryan made a suicidal Facebook post. The police were alerted and attended his flat and found him alive. However, he was not taken to a place of safety by the police under the Mental Health Act 1983. Instead, Ryan was left to his own devices to seek out mental health support the next day, which he never did. Furthermore, an email from the police to an NHS mental health nurse requesting a welfare check for Ryan was also missed.
On 1st August 2022, Ryan was found dead at his flat by the Police and Fire Service. He had died by asphyxiating himself.
In February 2023, Sarah’s partner, Karen, approached Advocate for help with representation at the Inquest into Ryan’s death. She had numerous issues with the Police and Mental Health Triage Team for their failings in their actions between the date of the original incident and Ryan’s suicide.
Advocate Panel Members Markus Findlay of Doughty Street Chambers volunteered to assist, led by Sunyana Sharma of 3PB. Through Advocate’s partner project Pro Bono Connect, they were also supported by a team of pro bono lawyers at the city firm Arnold & Porter which included Adela Williams, Jacqueline Mulryne, Eleri Abreo, and Katya Farkas.
Through written submissions, the team successfully persuaded the Assistant Coroner that it was appropriate for a jury to determine this inquest. The family welcomed this decision.
The inquest ran for two days in September 2024 at Horsham Coroners’ Court. The jury concluded that Ryan had died by suicide.
The Assistant Coroner expressed concern regarding the police’s lack of mental health training and was curious as to how the information flow would function between the police and the Rapid Response Unit, which would replace the Street Triage Team who had been operating at the time of Ryan’s death.
After the inquest and further disclosure from the parties, the Assistant Coroner deemed it necessary to publish a Prevention of Future Deaths (PFD) report which repeated his concerns. In regards to the police training, he concluded that “it has not been effective and is not repeated as often as may be required to provide officers with the necessary skills and knowledge.”
He also criticised the Street Triage Team for the lack of previous or planned training with the police, stating: “I am concerned that the importance of sharing all relevant information will not be understood unless each organisation understands what information to provide to the other or what questions to ask.” The PFD report was sent to the police Chief Constable and the CEO of the NHS Trust, who are both obliged to respond within 56 days with details of action taken or proposed to be taken.
Commenting on the support of Advocate, Karen said:
“If it wasn't for Advocate, we would never have had our case heard. In the early days when Ryan died, I worked every weekend trying to learn how to negotiate a coroner's court and what I was going to say when the time came to the inquest. Then I discovered Advocate, who kindly supported us. Sarah and I could have never got to the point where Ryan's case was heard by a jury without the support of Advocate and the caseworkers. Your expertise, dedication and unwavering support were instrumental in navigating us through this challenging time. I am really grateful to the caseworkers for their clear communication at every stage”.
Commenting on Markus’ and Sunyana’s assistance, Karen said:
“You gave us hope that we would be heard and restored my faith in human nature that there are still kind and wonderful people out there that care enough to give up their own time to support us at this difficult time and again for that we are truly grateful”.
Read more about the case in this BBC News article.
Read more of Advocate’s applicant stories.