John Hurst

I am David Place, His Majesty’s Assistant Coroner for the City of Sunderland

On 29 th September 2021 I opened and adjourned an Inquest into the death of Mr John Paul Hurst, who was born on 19 th May 1972 and who died [REDACTED] on 15 th September 2021 aged 49 years. The Inquest was heard on 9 th October 2024 and concluded on 11 th October 2024. The conclusion of the Inquest was ‘John Paul Hurst had a diagnosis of paranoid  schizophrenia with a long history of mental health difficulties and was the main carer for  his father. Having initially been arrested in connection with the death of his father and  subsequently de-arrested and then re-arrested on suspicion of an offence of possession of a controlled substance he was released from custody under investigation and then died [REDACTED] on 15th September 2021 from the  effects of bleeding from trauma consistent with the amputation of the lower half of his  right leg which is consistent with impact with a passing train in circumstances which  cannot be explained.’ The medical cause of death was: – Ia Right Lower Limb Injury

John Paul Hurst had a medical history of a diagnosis of paranoid schizophrenia. He had  previously attempted to take his own life on three occasions between 2000 and 2002, and had been sectioned under the Mental Health Act during the same period. John lived with his father and was his main carer. His father sadly passed away on 12 th September 2021. Due to concerns around the length of time before John had sought  assistance from emergency services, his demeanour upon police arrival and notes  containing disturbing content within the premises, John was initially arrested on suspicion of involuntary manslaughter. He was quickly de-arrested for that offence and re-arrested  on suspicion of possession of a controlled substance. Concerns were raised by police officers involved in the investigation about his mental  health due to John’s demeanour, the volume and content of the notes found at the scene  and detailed concerns expressed by his sister regarding a risk of him ending his own life upon release. John was assessed by Criminal Justice Liaison and Diversion Service (CJLD) and deemed fit for interview and release from custody. Following his interview, John was released from custody at around 4pm on 13 th September 2021. He last spoke to his sister at around 9.44pm on 13 th September 2021. On the afternoon of 15 th September 2021, John was found by a passer-by in undergrowth near to the train tracks [REDACTED]. John died due to the effects of haemorrhage from the tearing and loss of the  lower half of his right leg consistent with impact with a train moving at high speed.

During the course of the Inquest the evidence revealed a matter giving rise to 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 MATTER OF CONCERN is: – At the Inquest I heard evidence that, following John’s arrest, concerns were expressed by  police officers involved in the investigation as to his mental health, and by John’s sister as to his risk of ending his own life. These concerns were repeated by John’s sister to the  Criminal Justice Liaison and Diversion Service (CJLD) prior to his assessment. The  evidence was that when completing the release risk assessment, the custody sergeant had  been greatly assisted by the information recorded on the electronic custody record  regarding the concerns that led to the mental health assessment and the assessment itself,  in addition to the custody sergeant’s own observations. The evidence highlighted that the  electronic custody record contained limited information about the concerns of police  officers and John’s sister, and there was a distinct lack of detail about the assessment itself and very little analysis of the concerns and reasoning for the CJLD conclusion. I am concerned that the information on the electronic custody record was inadequate and  lacked detail regarding the concerns for the detained person’s mental health, as identified  by police officers and family, including the risk of suicide, the content of notes found and the detained persons history of suicidal ideation and previous engagement with mental  health services. In addition, I am concerned that the record also lacked a detailed analysis of those concerns by CJLD and comprehensive reasoning for the assessment conclusion. Deaths may be prevented if the recording of information in such cases is reviewed.

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.