concluded the inquest Into the death of Kieran Luke Hubbard on the 12th December 2019 and the jury recorded that died from 1a Hanging came to the Conclusion Suicide

The deceased was born on the 16lh August 1998 and was found dead on the 8h February 2019 hanging from a ligature made from a metal cable attached to the structure of a building In the process of construction at Vuclan Mill Phase 2, Off Malta Street Ancoats Manchester A Post Mortem examination confirmed the pathological cause of death to be 1a Hanging Toxicological analysis established the presence of citalopram, venlafaxine and diazepam: All of these were in therapeutic amounts There was a very small amount of alcohol found that this could be due to post-mortem microbial fermentation Following the death a serious Incident Investigation was carried out chaired by a mental health nurse but not a consultant psychiatrist and no was psychiatrist recorded as being a member of the review team or from whom advice was sought: Statements were taken from a number of healthcare professionals who had been Involved in his care and management and in particular from the consultant psychiatrist who saw him and made Importantlcrucial assessments and decisions about his_ care and management As a child he was diagnosed Bury wIth ADHD and as a teenager began taking a number of illicit drugs His father ran a construction business and was able to provide employment for him The deceased had no fear of heights and was able to work as what IS called a "Slinger" Over a period of some years to suffer depressive disorder was preoccupied or obsessed wIth sulcide At times he could become anxious or distressed and would often phone his father for support and as able to calm him down On a family holiday In 2017 he appeared to have a mental health crisis and disclosed his father as he contemplated jumping off buildings he was working on Upon returning from this holiday he agreed to seek counselling but was reluctant to engage with other mental health and GP services concerning his overall mental health problems However, he did accept a prescription of antidepressant medication In November 2018 he and his partner had a son after their relationship began in 2017 However, shortly after the birth this relationship came to an end and he was extremely distressed, His partner had another child from a previous partner and he was concerned about not being able to have contact with both children He experienced difficulties in agreeing arrangements with his former partner to see his son and things came to a head on 26 January 2019 when his former partner cancelled a prearranged contact at the last minute He was very distressed by this later the same day was found on a bridge above the motorway In West Yorkshire contemplating sulcide by jumping off it He was detained under S 136 of the Mental Health Act and taken to a place of safety At this time he was still in employment and had an address In Salford, Manchester but registered with a GP In a different local area a short distance away There are two primary mental health NHS Trusts In Greater Manchester One IS called Greater Manchester Mental Health NHS Trust (GMMH): The other is Pennine Care foundation Mental Health NHS Trust (PCFT) Information was passed to GMMH from local mental health services In Yorkshire and he was seen for the first time 28 January 2019 for an Initial assessment In one of the Trusts psychiatric units having attended their voluntarily Thereafter he had intermittent contact with healthcare professionals although agreed that he needed help An experienced consultant psychiatrist working for GMMH first became aware of as being a patient on 4 February 2019 at an MDT meeting She raised concerns about him driving a motor vehicle when suffering from an acute mental health crisis but understood that there was no clear operational policy dealing with this WIthin the trust This psychiatrist first met the deceased and 6 February 2019 when she undertook a detailed interview and psychiatric assessment She concluded that you suffered severe depressive episode which have been progressively getting worse since December 2018 and marked by recurrent suicidal thoughts At the time of this Interview he denied any current active thoughts of sulcide but disclosed that he felt helpless at their frequency and intensity She advised him not to drive at this time was not suitable for home treatment but that he should be admitted to hospital for ongoing assessment and treatment and he indicated that he was Willing to cooperate and do this His medication was changed but the psychiatrist concluded that he required aggressive treatment of his depression In a protected and supervised environment Initial enquiries indicated that there was no bed avallable locally within the GMMH facilities Since he was registered with a GP In what IS described as "outside area" which although being a very short distance away was within the catchment area of PCFT, The psychiatrist understood the other healthcare professionals would contact PCF Tin order to arrange for him to have a bed at one of their units unless one became avallable In GMMH, In the Interim the deceased indicated_bs willingness mental_health services_ The deceased discussed his case again him next MDT meeting on the morning of 8 February The psychiatrist understood that no bed was avallable but not that the search for a bed had been discontinued or the reasons why but felt that In the absence of an available bed care could be managed until Monday Ith of February when the position could be reassessed The psychiatrist was not Informed on 7 February that GMMH healthcare professionals have been in contact with PCFT but who had apparently requested further Information before considering the request bed and those healthcare professionals decided to abandon the attempt to secure a bed because of the deceased's apparent cooperation This was a lost opportunity to have reconsidered the position and pursue other arrangements or escalate the issue On the 8 February the psychiatrist was not updated and told of the accurate position The deceased's father received a phone call from hIs son mid-morning on that and he returned the call although was aware from a previous conversation that son had been advised not to drive a motor car but assured him that he could have the following week off work without any difficulty His parents lived In Norfolk but his father drove to Manchester In order to collect him and take him home for his own welfare and safety En-route to Manchester at about 4 30 PM he discovered that his son posted on Facebook that he was intending to take hIs own life. He asked his wife to contact GMMH wind and advised to contact the police A concern for the deceased's welfare was raised and his father went to the building site where his working and met police officers at that location at about 6.30 pm and facilitated their Into the site but also saw his son dead hanging from a ligature understandably extremely distressed and traumatised by what he had seen The police searched the deceased local home and found a number of notes to close members of hIs family and from those an Inference could be drawn that he wished to take his own life Subsequently, GMMH carried out a serious Incident Investigation produced a detailed report The Investigation was chaired by a mental health nurse but did not have a consultant psychiatrist on the investigation team The investigation Itself discovered that apparently PCFT wanted further Information In order to consider the request bed provided by them but he did not discover exactly what Information was requested although this IS clearly extremely relevant No contact was made with the appropriate level of management within PCFT to discover this and nor was this Issue escalated to senior management within GMMH The report itself which was bound to be disclosed to the deceased's family did not use plain simple English to describe Its relevant findings and In particular that the treating psychiatrist had not been made aware of the decision by other healthcare professionals to abandon the search for a bed and so lost the opportunity to make other alternative arrangements which were clinically appropriate In addition to provide the deceased with a safe and supervised environment In practical terms we psychiatrist decision to admit the deceased to hospital was overruled but without advising the psychiatrist and nor was it brought to her attention on the morning f 8 February

In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action: