Nikolas Clarke represented the local authority social services’ department in an inquest concerning MM, a 17-year-old young man, who died in February 2020.
MM was being housed by the local authority. He had a diagnosis of complex PTSD and a history of self-harm, suicidal thoughts and overdoses.
Background to the inquest
MM came under the care of the local authority in January 2019. From November 2019 he was in semi-independent living.
That month, following an allegation of a serious offence against him, which had not been substantiated at the time of his death, he was detained under section 136 Mental Health Act 1983.
He was assessed and as there was no evidence of psychosis, he was discharged to the care home.
In December and January he attended hospital following incidents of self-harm or overdoses. However on each occasion he left before any mental health assessment could take place.
During the first two months of 2020 he was reported missing on 15 occasions. On 25 February he left the care home and was reported missing to the police.
He boarded a train to Norwich. In the early hours of the morning, as the train came into the station he climbed on to its roof and was electrocuted. He was pronounced dead at the scene.
The coroner’s findings
The coroner concluded that MM’s death was misadventure. She considered MM’s history of self-harm and suicidal ideation. However, on the balance of probabilities and given the evidence, she concluded that he did not intend to end his own life.
As MM died with a spray can and toothpaste in hand (often used together in graffiti) and evidence showed he enjoyed art and aspired to becoming a tattooist, she found his death was an ‘unintended outcome of an intended act’.
The coroner made no report on preventing future deaths. Although some concerns had been raised during the course of the inquest, she noted that steps had been taken since so those concerns had fallen away.