The jury at the inquest into the death of 19-year-old Daniel Joe Mattin, of Guildford, has concluded that systemic failings caused or more than minimally contributed to his death. It also found that his death had been contributed to by neglect, a gross failure to provide basic care.

Daniel died on 4 June 2021 after he was allowed to leave Farnham Road Hospital against medical advice. He had been admitted on 2 May 2021 as a patient detained under section 2 of the Mental Health Act. At the time of his death he was a voluntary patient.

The Article 2 inquest at Woking Coroners Court examined the mental health care that Daniel received from Surrey and Borders Partnership NHS Trust, the Trust’s systems and the response of the Trust and Surrey Police on 4 June after Daniel was found to be missing from the hospital.

During his admission Daniel had continued to report to staff that he had thoughts of suicide and had also warned that he was selective with what information he shared.

On 1 June another patient reported to staff that Daniel had said he was still suicidal and that he planned to end his life in a few days. As a result, Daniel’s consultant psychiatrist instructed that Daniel should not leave the ward and that if he tried to leave consideration should be given to using Mental Health Act powers to stop him. This plan was later deleted from the Trust’s handover notes.

On 4 June a student mental health nurse allowed Daniel to leave the hospital at 11.50am. She told the Inquest that she had not been made aware of the consultant’s instructions and that no concerns had been raised about Daniel during the nurses’ handover meeting that morning. The student nurse also told the court that she was unaware that it was against Trust policy for unqualified staff to allow patients leave from the ward and said she had signed patients out on at least 10 occasions without being challenged by senior staff. She said she had seen other non-qualified staff also grant patients leave.

Two hours after Daniel left the ward the nurse in charge was told that he was absent. She did not invoke the Trust’s missing person’s policy and instead asked a healthcare assistant to telephone Daniel and tell him to return immediately. The healthcare assistant spoke to Daniel but agreed he could have another hour of leave.

When Daniel did not return after that further hour, the nurse in charge called Daniel and booked a taxi to collect him. A short while later Daniel left a voicemail for another patient indicating he was at immediate risk of suicide.

At 3.45pm, the nurse in charge called the police and explained that Daniel was a “high-risk missing person”. This was almost four hours after Daniel had left the ward and two hours since the nurse in charge been told of his absence.

Police and hospital staff searched for Daniel and a short time later a Farnham Road hospital staff member found Daniel, but he died at the scene of multiple injuries. Daniel’s mother, Dawn Marsh, was not informed by staff of his absence from the ward until after he had already died.

The jury concluded that systemic failings caused or more than materially contributed to Daniel’s death and that his death was contributed to by neglect, a gross failure to provide basic care. They found multiple failings that probably made a material contribution to Daniel’s death, including failings in the sharing of information about his care plan, management and leave arrangements; failings in the handover systems and staffing of ward rounds and multi-disciplinary meetings; and failings in the arrangements for granting leave to voluntary patients. It found further failings in the risk assessments and management processes; and in the Trust’s response when Daniel was noted to be absent from the ward on 4 June.

Daniel’s family was represented by Sophie Wells, with Caleb Bawdon, of Leigh Day, and Tayyiba Bajwa of Doughty Street Chambers.

Following the inquest Daniel’s mother, Dawn Marsh, and stepfather, Alan Marsh said:

“As parents we were, to a degree, relieved when Daniel was admitted to the care of Farnham Road hospital because we believed he would receive the professional help he needed at that point in his life.

“Through the process of this inquest it is apparent that our confidence in the system was misplaced and mistakes were made leading to the most dreadful of outcomes.

“We hope the pain we have endured results in more than cosmetic changes and real improvements are embedded for the care of patients.  This in turn, will hopefully provide future parents the reassurance that their loved ones receive the highest levels of care that is expected.”

Leigh Day solicitor Sophie Wells, said:

“The evidence which emerged at the inquest was damning and we are pleased that the jury has recognised that systemic failings caused or more than minimally contributed to Daniel’s death and that his death was contributed to by a gross failure to provide basic care. We hope this will now prompt the Trust to make long overdue changes. Staff said that they had been asking for years for systems to be modernised. Policies had been drafted but staff, including senior staff, did not have a detailed understanding of them. Key risk management records were saved outside the hospital’s main system, as Word or paper records.

“The jury identified multiple failings which, on the balance of probabilities, caused or more than minimally contributed to Daniel’s death. Dawn and Alan have sat through each day of the inquest as evidence of these and multiple other failings has emerged. I, like the Coroner, am in awe of the grace, resilience, and compassion with which they have done so. The testaments from Daniel’s friends show he was a credit to his family, and they have been a credit to his memory. It has been an honour to represent them in his inquest.”