Deaths Crisis: INQUEST challenges suitability of supported housing in care provision to young adults with serious, longstanding mental illness

The inquest into the ‘unexpected death’ of Daniel Chapman under the care of Norfolk and Suffolk NHS Foundation Trust (NSFT) started on Monday 19th September before the Suffolk coroner, Peter Dean, at Bury St Edmunds. The family is represented by Claire Mawer at 15 New Bridge Street and INQUEST Lawyer’s Group member Harriet Wistrich of Birnberg Peirce.

INQUEST reports:

19 September 2016

Two inquests have opened today which highlight trends seen in INQUEST’s casework around the suitability of care being provided to vulnerable adults with serious mental health issues.

  • D’Anna Joan Ward was a 20 year old young woman with a history of complex mental health problems, including significant self harming. She was found hanging in her bedroom at her privately run, supported living accommodation on 7th August 2015. In the last 10 months of her life, she visited emergency departments over 20 times and required admission as an inpatient on seven occasions following incidents of self harming, ligaturing and overdosing. Her family question whether her accommodation was the most appropriate placement to meet her complex needs.
  • Daniel Chapman was a 33 year old young man living with paranoid schizophrenia, who died as a result of an overdose of a legal high in Bury St Edmunds on 31st October 2014. He had been living in supported housing under the care of Norfolk and Suffolk Mental Health Trust and Julian Support (who provided independent living support). He was susceptible to inappropriate peer pressure and the family felt that he was let down by those responsible for his care.

Deborah Coles, Director of INQUEST said:

“Women, young people and those with mental illness form a high percentage of INQUEST’s casework. Time and again we see inadequate care and support provided to the most vulnerable individuals, in the one place they should feel safe.

These inquests provide an important opportunity to scrutinise what happened to D’Anna and Daniel and to gain insight into how future deaths might be prevented”.

Daniel’s mother, Linda Durrant, commented:

“My son was a very vulnerable young man and reliant on the agencies responsible for his care to keep him safe and alert me to any risks.  I am concerned that I was shut out of the process and there was a failure of communication in this case which prevented me from ensuring my son was not at risk. I hope the inquest answers the questions I have regarding the care and support provided to him”.

Why has it taken nearly TWO YEARS for the death of Daniel Chapman to come before the Coroner? We hear repeatedly about NSFT delaying inquests.

Yet more deaths.

Enough is enough!

Even with the hard work of charities like INQUEST, the inquest system remains stacked against families.

You can read the INQUEST statement in full by clicking on the image below:


5 thoughts on “Deaths Crisis: INQUEST challenges suitability of supported housing in care provision to young adults with serious, longstanding mental illness”

  1. The Mental Health Act strikes again. How many SUIs, unexpected deaths and suicides could be prevented if carers are warned when it is obvious that SUs are at risk? There is a legal cause of death, I am told: DEATH BY NEGLECT.

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