NHS failure possibly contributed to suicide - coroner

Dan Kay had a close relationship with the families of the Hillsborough tragedy victims and was an active campaigner in their fight for justice

The failure of a community mental health team to visit a Liverpool man days after he tried to take his own life "possibly contributed" to his suicide, a coroner ruled.

The body of Dan Kay, 45, was found on a railway line in Mossley Hill in the city on 7 May last year.

Speaking outside the Gerard Majella Courthouse at the conclusion of his inquest, the family of the journalist and Hillsborough campaigner said mental health professionals should have "tried harder" to make sure he was safe.

The inquest heard Mr Kay had attempted to take his own life twice in the days before he died and had been taken to hospital on 1 May.

Amos Waldman, Mr Kay's cousin (left) and Dr Steven Waldman, his uncle, pictured after the inquest

He was discharged with the understanding he would receive daily visits from a specialist mental health team.

The inquest heard on 5 May this was downgraded to phone calls and face-to-face visits on alternate days - a decision made by one staff member acting alone with no formal risk assessment.

Mr Kay was then believed to have called the team on 6 May cancelling a visit the following day - which should have "raised alarm bells".

Assistant coroner Joseph Hart said: "The reasons for his cancellation were not recorded or explored by the team under whose care Dan was.

"The lack of a visit on the day of Dan's death, in the absence of a visit in person the day before, could have had a real prospect of eventuating a different outcome.

"The absence of formal consideration of the support needs possibly contributed to Dan's death."

Dan Kay had suffered with mental health difficulties for decades before his death

Mr Hart told the inquest that mistakes and missed opportunities by Mersey Care NHS Foundation Trust amounted to an "arguable breach" of Mr Kay's right to life under Article 2 of the European Convention on Human Rights.

During the inquest, Mersey Care crisis team member Matthew Wigley told the court he did not know why the 7 May visit was cancelled, adding: "It was a huge mistake and I’m sorry."

Mr Kay, a journalist for the Liverpool Echo newspaper and a campaigner who worked with families of the Hillsborough disaster victims, was described as "warm, generous and caring" by his family.

His cousin Amos Waldman said after the inquest concluded: "It was incredibly frustrating that these opportunities were missed.

"Dan should have been here now."

Mr Waldman said it was "disappointing" that mental health workers had not "tried harder to ensure Dan was safe".

'Let down'

He added: "We do feel that in the days before his death that Dan was let down by the team of people that was supposed to be there to give him the care and support he needed."

The inquest had heard Dan, who struggled with mental health difficulties for many years and had tried to take his own life about 26 years earlier.

In the months before he died his mental health had deteriorated significantly after a rescue dog he had adopted had to be put down due to its aggressive behaviour.

Leanne Devine, a partner at Leigh Day solicitors which represented Mr Kay's family, said after the hearing: “It is a tragedy that someone who was so loved and respected in his personal and professional life, suffered so badly with poor mental health to the extent that it put his life at risk.

"It is a greater tragedy that errors were made by the team tasked with keeping Dan safe in days of crisis in early May 2023."

A Mersey Care spokesperson said the trust "prided itself on being a learning organisation".

It said: "Immediately after this incident we conducted a serious incident investigation and have updated our practices in line with recommendations from our internal review."