On 17lh August 2015 commenced an investigation into the death of Michael Peter McMonigle; ("Michael") born 25ih October 1969. The investigation concluded at the end of the inquest on 8h August 2016. The conclusion of the inquest was Suicide, contributed to by neglect: The jury stated made the following entries in Boxes 3 and 4 of the Record of Inquest; including a narrative on issues in Box 4: Box 3: Michael McMonigle was admitted at a voluntary patient to the Farnham Ward at Lanchester Road Hospital on 5ih August 2015. Michael was able to leave the hospital unaccompanied on August 2015 , leading to his death on 11 in woodland at Trinity School; Trout Lane, Lanchester, Co. Durham by suspension by ligature and was declared dead at 07.35 hrs on 2th August 2015_ On the balance of probabilities the jury concluded that the admitted failure of not updating the face risk assessment; PARIS case notes and intervention plan with the assessment of risk of self-harm or suicide and the conditions tor escorted leave made at a formulation meeting on 10h August 2015 probably more than minimally or trivially contributed t0 Michael's death: The manner and extent that Michael's family were informed of the assessment of risk the conditions for escorted leave following the formulation meeting on 10"h August probably more than minimally or trivially contributed to Michael's death: The manner in which the handover to his family was prepared for and conducted when Michael left the ward on 11hh August 2015 probably more than minimally or trivially contributed to Michael's death: Finally, the lapse of time between Michael leaving the hospital on 11lh August 2015 and when it was recognised he might be a missing patient probably more than minimally or trivially contributed to Michael's death: Box 4: In conclusion Michael's death was caused by suicide whilst the balance of his mind was disturbed: His death was contributed to by neglect: Due to inadequate communication of potentially significant information between Michael's family and staff members, Michael was at significant risk on 11lh. Trust leave policy was not fulfilled to a satisfactory level and staff knowledge of policy, particularly from the Consultant Psychiatrist was unsatisfactory: Whilst the jury thought that the policy was adequate, the failure of staff to recognise and fulfil all aspects of the policy was severely lacking and probably more key and put than minimally or trivially directly contributed to Michael s death Appendix 3 Missing Patient report completed after Michael was found to be missing the jury held to be lacking in that not all initial actions deemed vital were fulfilled. They heal it evident that there were several occasions prior to 22.OOhrs where the alarm of Michael's absence could have been raised particularly from 19.20 to 21:00 hrs: Finally the effect that business and staff pressure had on the leave and death of Michael on 11 August was a contributing factor t0 Michael's death of note, the lack of handover to Michaels parents on 11th by the Acting Ward Manager which did not fulfil the Trust policy best practice and was therefore insufficient:

In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action YouR RESPONSE You are under a duty to respond to this report within 56 of the date of this report; namely by 10lh October 2016. 1, the Coroner; may extend the period. Your response must contain details of action taken or proposed to be taken, setling out the timetable for action. Otherwise you must explain why no action is proposed_