Adam Gallagher
PFD Report
Historic (No Identified Response)
Ref: 2022-0292
Coroner's Concerns (AI summary)
The ambulance service failed to conduct a detailed assessment for a mental health incident, resulting in inadequate clinical input and limited learning from a serious event. Trust-wide policy review and comprehensive retraining are urgently required.
View full coroner's concerns
(1) NEAS Trust confirmed in evidence that a more detailed assessment of AG should have been undertaken and Clinical input sought leading to Ambulance dispatch and potentially an alternative outcome for AG. Learning from the incident was limited to 'discussion' with 2 staff involved. Serious events of this nature should be subject of Trust wide learning and training to prevent future deaths.
(2) Comprehensive retraining is required for those directly involved. (3)An urgent review of Trust policy/protocol for handling/management of mental health related incidents should be undertaken and associated training in respect thereof. (4)Trust to review the events leading to AG's death and identify any additional safeguards they may put in place to prevent future deaths.
(2) Comprehensive retraining is required for those directly involved. (3)An urgent review of Trust policy/protocol for handling/management of mental health related incidents should be undertaken and associated training in respect thereof. (4)Trust to review the events leading to AG's death and identify any additional safeguards they may put in place to prevent future deaths.
Sent To
- North East Ambulance Service
Response Status
Linked responses
0 of 1
56-Day Deadline
10 Nov 2022
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 21 October 2021 I commenced an investigation into the death of Adam GALLAGHER. The investigation concluded at the end of the inquest . The conclusion of the inquest was Adam GALLAGHER died due to his own actions whilst under the influence of alcohol to which a missed opportunity for urgent intervention contributed. 1a Pressure on the Neck 1b Hanging 1c
Circumstances of the Death
Adam Gallagher was 30 years old. He had a history of Mental health issues and alcohol Dependence Syndrome. On 17th October 2021 whilst under the influence of Alcohol he 4 communicated suicidal ideation by text message to a friend who shared this information and details of his mental health history, including previous hospital admission under MHA 1983 with NEAS via 999call. NEAS Health Advisor contacted AG by telephone; the call was short ,only limited 8 assessment of his Capacity and Risk was undertaken, No Clinical input was sought and Ambulance was NOT dispatched. At around 9am on 18th October AG was found where his death was confirmed.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.