Family say they have been let down by the inquest process and the conclusions touching upon the death of Rowan Morrall

The inquest into the death of Rowan Morrall has concluded, with the coroner, HMC Pears finding a conclusion of suicide with no causative or contributory factors.

Rowan Morrall died on 21 September 2016. He was found hanging in his flat in Bedford by his father, David Morrall, and a psychiatric nurse from the Bedford Crisis Home Resolution Treatment Team. Less than two days before his death, Rowan had been held under section pursuant to section 2 of the Mental Health Act 1983 and was being treated on the Coral Ward, Luton and Central Bedfordshire Mental Health Unit. He was released from section and from the Coral Ward on 19 September 2016. Prior to the inquest taking place on 21 and 22 March 2018 the family made a complaint about HMC Pears to the Judicial Conduct and Investigations Office (JCIO) and made two written applications and one oral application for the Coroner to recuse himself from hearing the inquest. The Coroner refused to recuse himself.

The family of Rowan Morrall maintain he should not have been released from section and discharged from the Coral Ward on this day. They were not informed about either event before they took place, and the family were due to attend a consultant review meeting on 21 September 2016, which is the date of Rowan’s death. Rowan had made it clear to his family that he was still hearing voices and was having suicidal thoughts, and the family communicated this information to staff on the Coral Ward. But their concerns and this vital information was not relayed to the staff as promised, including the consultant in charge, who took the decision to discharge Rowan. Rowan went on to take his own life less than 48 hours later.

The Trust failed to follow the procedures it had in place to safeguard patients being discharged from its secure mental health unit. Rowan was released without a discharge planning meeting, in breach of the Trust’s Care Programme Approach. As a result, there was a failure to bring together the different health professionals involved in Rowan’s care to consider his discharge. Similarly, the Trust failed to hold a multi-disciplinary meeting with the family and Rowan’s care co-ordinator before his discharge. As a result, vital information Rowan’s family had about his mental state and suicidal intent was not taken into account on discharge. Crucially, Rowan’s family were not informed that he was at an increased risk to himself or harm in the days immediately after his discharge.

The family of Rowan have felt let down by the inquest process, which they feel has not allowed them a fair and impartial hearing of the circumstances leading to his death. The family feel that the Acting Senior Coroner sitting on the inquest has been dismissive, defensive and hostile. Rowan’s family have been shocked and devastated by this. At the end of the evidence HMC Pears refused to confirm he would deliver a conclusion in public. After representations from the family a hearing was later listed for the conclusions and determinations today, on 13 June 2018.

Rowan’s family said:

“Rowan was a bright, creative, curious man and he was very-much loved by his family.
We feel devastated and completely let down by the Coroner’s handling of Rowan’s inquest and the conclusion. We found the inquest process to be combative and difficult, and we feel like our views were not taken on board and listened to by the Coroner or East London Foundation NHS Trust. It has been the opposite of what we expected from the inquest.

Our view is that Rowan would still be with us if we had been listened to, and if he had remained on the Coral Ward until at least 21 September 2016 when we were due to have a meeting with the consultant psychiatrist, who admitted in evidence that the outcome may have been different if our views had been taken on board.

It is also clear from the evidence that the Trust failed to follow its own procedures for safeguarding patients being discharged from the secure unit Rowan was in. So no discharge planning meeting was held, in breach of the Trust’s policy and recommended best practice, and we were not invited to a multi-disciplinary planning meeting which would have provided an opportunity for the Trust staff looking after Rowan to consider how to keep him well and safe. We believe that, had we been able to attend such a meeting, Rowan would in all likelihood not have been discharged. When Rowan was discharged we were not told by the Trust about the high risk he was at of suicide in the days following his release. If we had known this we would have been able to put measures in place which would have meant he was still with us today.

We sadly consider the Coroner has been arrogant and dismissive of our concerns and the shortcomings related to Rowan’s discharge and we are also concerned for other families who face injustices in the inquest process due to the views and manner of this coroner.”

The solicitor for the family, Harpreet Aujla of Matthew Gold and Company Limited solicitors, said:

“Rowan’s family have bravely participated in this inquest despite feeling their views have been dismissed by the Coroner. No family should have to feel like this following the death of a loved one and the family of Rowan Morrall support calls for improvements to the coronial system for bereaved families and a truly effective and independent forum for raising complaints about the conduct of coroners to improve families’ faith and experience in the inquest system.”

This case has been reported in the media including the BBC.