Sean Heath

Christopher Murray HM Assistant Coroner  Manchester South Coronial Area Mount Tabor Stockport

On 29 th August 2023 an investigation was commenced into the death of Michael Sean Heath aged 35. The investigation concluded at the end of the inquest on 30 th September 2024. A jury made a determination that Michael Sean Heath died by taking his own life by [REDACTED] whilst suffering from an acute episode of a mental health crisis.

On 25th August 2023 Michael Sean Heath died in apartment [REDACTED] Manchester as a result of a fatal [REDACTED] which penetrated his pericardial sac. He had been suffering with mental health issues  for several years. Having considered the evidence, on the balance of  probabilities we have identified the following contributing factors – 1) The decision to close the police log on the 25th August 2023 and the police not attending Michael resulted in a missed opportunity for a welfare check, 2) Poor inter agency communication and failures to follow up any outstanding  action points, in particular the failure of the Trafford North West Mental Health team to chase up the date when Michael was due to return from Gibraltar and  investigate the blank email with Michael’s identifier. In addition, the failure of  Trafford Council Adult Social Care to verify that police were attending on the  25th August 2023. 3) The failure of mental health services in Gibraltar to notify Trafford Mental  Health Team of the exact date of Michael’s return to the United Kingdom. This  resulted in a lack of mental health support when he returned. 4) The lack of probing by North West Ambulance Service mental health  practitioner during telephone triage on 23rd August 2023 resulted in a missed  opportunity for a face to face assessment. 5) Michael’s mental health condition and his reluctance to take his psychiatric medication consistently and his reluctance to engage with mental health  services or General practitioner.

The evidence heard during the inquest into Michael Sean Heath’s death and the findings of the jury confirmed there were a number of factors contributing to  Michael’s death which are of concern. In my opinion, there is a risk that future  deaths will occur unless action is taken. In the circumstances, it is my statutory  duty to report to you. The MATTERS OF CONCERN are as follows – In relation to Policing is the extent to which all officers are trained to assess the  increasing number of calls to the police which are of a mental health nature, the risks associated with the consequences of not making the right assessment  where there may be an immediate risk to life and when to accept that the police are the right agency to be involved in mantal health related enquiries due to their powers of entry; In relation to the management of mental health patients that their carers are  made aware of any admission under the Mental Health Act within 24 hours and those patients are supported with access to an independent mental health  advocate; The apparent lack of connectivity between mental health services abroad and the UK upon repatriation whilst the patient remains ill; That there is a risk to patients generated by a decision to remove a patient from a GP practice list where the patient resides out of geographical area for that GP  practice without considering the wider circumstances and the likely follow on  care; and The means of communication is known and agreed between all mental health agencies to ensure all relevant patient information is held in an accessible  central repository.

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