'Our son died after he should have been sectioned'

Deborah and Phil Cochrane said they felt mental health professionals had not listened

A coroner has raised concerns over the care of a man who died hours after mental health clinicians decided not to section him.

James Cochrane died at about 21:00 GMT on 17 November 2023 on the M1, near Shepshed in Leicestershire.

James had been diagnosed with schizoaffective disorder and was in the care of the Leicestershire Partnership NHS Trust.

His parents, Phil and Deborah, had recorded a video of him "shaking and rocking" during a psychotic episode on the day of his death, and told the BBC they had been desperate for him to be sectioned.

An inquest into James's death, which concluded on Wednesday, heard trust nurses came to assess the 36-year-old at his parents' home at about 16:00, and decided not to refer him for an assessment to be detained under the Mental Health Act.

Assistant coroner for North Leicestershire and Rutland, Rebecca Connell, said she was concerned about a decision to leave James with his parents over the weekend while increasing his dose of anti-psychotic medication and drugs to help him sleep.

Mrs Connell said she would be preparing a prevention of future deaths report detailing concerns after the two-day inquest at County Hall in Glenfield.

The NHS trust said lessons had been learned following a review carried out after James's death.

James Cochrane died when he suffered catastrophic injuries

Mrs Connell said there had also been a missed opportunity to assess a change to James's medication in October 2022, because notes had not been seen by a psychiatric consultant involved in his care.

The inquest heard James's medication had been changed after he said he was worried about weight gain and lethargy, but after the change he began to experience more psychotic episodes.

Mrs Connell said her concerns also included whether there was enough support for carers supporting mental health patients, and whether clinicians should consider video evidence when considering an application to section someone.

She said she was concerned not enough weight had been given to the video when it was shown to a nurse assessing James, including on the day he died and that had been a missed opportunity to help him.

James's parents said they feared no lessons had been learned by the trust after their son's death

James's parents said they recorded the video - in which James was claiming to be God - to prove their son's mental health had collapsed, because they did not think trust staff believed how badly he had deteriorated.

The coroner asked several trust staff if, having seen the video, they thought it was appropriate to have left James with his parents over the weekend with advice to call a 24/7 phone line should his condition worsen.

The court heard James's mother made a number of calls to the trust on the day of his death, and also called the police because it was feared he might harm himself.

The inquest heard trust mental health practitioner and team leader Carmella Paterson attended the family home to assess James on the afternoon of 17 November.

Ms Paterson said she watched part of the video of James, but when she saw him in person he was not in a psychotic state.

She told the inquest she felt "uncomfortable" watching it as she was unclear as to whether James had consented to it being recorded.

She told the coroner she initially believed at the time the video may have been staged - but later told the inquest she did not believe it had been.

She said: "I saw the video but that's not how I saw James at the time.

"I didn't feel he [James] met the threshold for an assessment under the Mental Health Act at the time."

Ms Patterson added: "I believe the plan put in place at the time was safe. I believed it was the least restrictive, most appropriate outcome at that time."

The inquest was told James's parents said his mental state was the worst they had seen it since 2012, when he was detained in the Bradgate Mental Health Unit in Glenfield.

Deborah told the hearing they could clearly see James getting worse but that he had been able to "mask" his condition when talking to trust staff.

'We wanted help'

The coroner recorded a narrative conclusion, saying James had died of catastrophic injuries when he was struck by a vehicle travelling along the motorway.

The inquest heard James had left the family home earlier, and his brother Stuart had found him on the motorway shortly after.

The coroner added: "It is unclear if he was having a depressive or psychotic episode at the time of the incident, and therefore it is impossible to say whether James intended the consequence of the act."

She recorded a secondary cause of death as schizoaffective disorder.

The coroner, who fought back tears during the hearing as she read tributes to James by his brother Stuart, said she was concerned there had been missed opportunities to help.

After the hearing, the trust said: "We would like to offer our deepest condolences to the family and friends of James Cochrane. Following James's sad passing we conducted our own internal investigation.

"Mr Cochrane's family had input into the final report and lessons learned have been discussed and implemented in relevant teams.

"We will consider the coroner's findings in more detail when we receive the final report."

James's dad Phil added: "I actually don't think they have learned anything. We need a massive overhaul of mental health services.

"We were not listened to when we were telling them how bad James was.

"We wanted help. We did not get it."

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