A 28-year-old father-of-two, Niall Tyrrell, was found dead in his room in a psychiatric ward in Manchester in May 2022 as a result of a fundamental failing in his mental health care, according to the findings of an inquest into his death, which concluded last week. Ison Harrison’s nationally-renowned inquest solicitor, Ruth Bundey, represented the family of the deceased and branded the failings “inexcusable”.

Niall Tyrrell was a loving father and, according to his family, could be “the life and soul of the party”, but he had also suffered from a long history of depression and self-harm. He had been sectioned under the Mental Health Act and was in the care of the Greater Manchester Mental Health Trust, located at Park House, which is in the grounds of North Manchester General Hospital. In April 2022, Niall attempted to abscond from the hospital and harm himself, and this triggered a move from his room on the Mulberry ward to Juniper ward, the intensive care unit.

Care regime downgraded

It was during this move that a fundamental failing in the patient’s care led to his suicide. On the Mulberry ward, prior to transfer Niall had been subject to 1:1 observation, a care regime under which he was observed by a staff member at all times, and was the result of his escalating mental health condition. However, when he was moved to Juniper ward, his notes were not checked and he was downgraded to a less intensive care regime, under which he was only checked and observed every fifteen minutes.

During one of these observation breaks, on May 2nd 2022, Niall hung himself while alone in his room and was found unresponsive.

The Greater Manchester Mental Health Trust, who run the psychiatric unit admitted to failings in downgrading Niall’s 1:1 observations despite documents being available detailing his current risks. Following the inquest’s conclusion, a Trust statement read: “Niall’s death was a tragedy and our deepest sympathies and apologies go to his family and all who cared for him. Since his unexpected death and following our own internal review last year, we have made a number of improvements to our clinical procedures, supported by additional training for staff. To maintain this improvement we have strengthened our systems to monitor practice.”

“Inexcusable” failings claimed by inquest solicitor

Niall’s family point to a “broken system” in mental health care contributing to Niall’s death. His mother, Joanne Tyrell, said: “I just think it’s disgusting, Risk assessments are there for a reason; everyone is an individual. It wasn’t one error from one person, it was multiple errors from multiple people.”

Ruth Bundey, Ison Harrison’s solicitor and a member of the Inquest Lawyers Group, representing the family said: “There were serious failures in the management of Niall’s clinical care which should have mitigated known ligature risks. In addition, on the last day of this life, his mother alerted ward staff time and time again to his constant suicidal ideation but no further risk assessments took place.”

The inquest jury concluded that Niall Tyrrell died of suicide contributed to by neglect.


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