Jamie Pilkington

I am Andrew R. Barkley, Senior Coroner for the coroner area of Staffordshire and Stoke on Trent

On 23 March 2023 I commenced an investigation into the death of Jamie Peter Norman PILKINGTON aged 51. The investigation concluded at the end of the inquest on 13 February 2024. The conclusion of the inquest was that of “Road traffic collision”

The deceased passed away in his vehicle which had left the road, struck a tree and caught fire in the early hours of the morning of 12th March 2023 on Port Lane, a short distance from Whitehouse Lane, Codsall, Staffordshire. He was confirmed deceased at the scene. He was, at the time of the collision, under the care of the Mental Health Services and had been expressing suicidal thoughts, something with which he had suffered for many years. There was no evidence to suggest that he left the road intentionally.

During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) During a Mental Health triage with the the Mental Health and Social Inclusion Hub on 8th February 2023 there was a failure to complete the Risk Assessment in relation to his risk of suicide. When referred to and assessed by the Integrated Mental health Team on 3rd March 2023 again there was a failure to complete a Risk Assessment as to his risk of suicide. Furthermore, in an appointment on 3rd March 2023  Suicidal/self-harm thoughts not explored in detail. There was no exploration of his statement to the effect he was actively researching methods of taking his own life. There was no exploration regarding efficacy/concordance with medication. There was no discussion around distraction techniques, coping mechanisms or information about contact details for other services. There was no discussion regarding his support network, next of kin etc. There was no indication of next steps, timescales or when he could expect to be informed of the onward plan and no definite date when his case would be discussed with the Multi Disciplinary Team. On hearing evidence of the investigation into the Mental Health care which he received, beyond offering further training and support to nursing staff and mental health professionals, no assurance could be given of a system change to ensure that such Risk Assessments were completed or that appropriate and adequate exploration is made of matters which may affect how the risk of suicide is managed.

In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action.