Marshall Metcalfe died after suffering “catastrophic internal injuries” after falling from a building on 7 May last year
The health trust that was responsible for treating a Lytham teenager who took his own life has revealed changes have been made following the young man’s death.
Marshall Metcalfe, 17, who was born in Burnley, suffered “catastrophic internal injuries” after falling from a building in Blackpool on 7 May last year. He tragically died after the incident.
Exactly a month later, his mum Jane Ireland was found dead at home after taking non-prescribed heroin substitute medication methadone.
The pair both suffered from mental health issues. Marshall, who had been diagnosed with psychosis, had spent two spells as an in-patient at Tier Four unit The Cove in Lancashire prior to his death.
An inquest concluded last month with Senior Coroner Alan Wilson ruling that Marshall’s death was suicide. A narrative conclusion was recorded in relation to his mum’s death.
“Marshall is believed to have left his home on May 7, 2020, at 12 noon,” the coroner said.
“Witnesses said his face was expressionless, blank and showed no emotion.”
The coroner revealed that prior to Marshall’s death the owners of the building had been asked to put up permanent barriers to prevent anyone from taking their own life there. However, because of coronavirus, temporary barriers could only be put up which were replaced, a month after Marshall’s death, with permanent fixtures.
The inquest had heard from expert witnesses who said that when Marshall had been discharged from The Cove in January 2020, after his second admission, children’s social care had closed his case and were no longer involved. Although Marshall was re-referred this didn’t take place until two months later.
Earlier in the inquest the coroner heard from Brendan Lee, the head of service for children and social care at Lancashire County Council, who admitted that the council had identified a number of areas for lessons to be learned following Marshall’s death.
He revealed that staff at The Cove had a “strong feeling that children’s social care should remain involved in Marshall’s case” because of concerns about his mum’s own mental health and “capacity to parent” Marshall. One expert witness described the lack of links between health and social care represented a “missed opportunity”.
Staff from The Cove sent what is known as a Section 85 letter to Lancashire County Council, notifying them he had been discharged, but the letter was not passed on to social services. Marshall, who was born in Burnley and lived with his mum in Lytham, subsequently went without support from social services for several weeks.
Although some changes have been made at social services since Marshall’s death the coroner remained concerned that social services had not remained involved in his care after he was admitted to The Cove and at the conclusion of the inquest he revealed his intention to send what is known as a Prevention of Future Deaths Report to Gillian Keegan, the Minister of State for Care at the Department of Health and Social Care.
‘Lesson learning opportunities’
A spokesperson for Lancashire and South Cumbria NHS Foundation Trust told LancsLive: “We would like to express our heartfelt condolences to Jane and Marshall’s family and friends.
“Our thoughts are with them at this difficult time.
“Following the incidents, we undertook two detailed investigations, both of which identified lesson learning opportunities for the Trust.
“We have already made changes based on these findings, these most notably include enhancing our safeguarding and Think Family training, improving our relationship and inter-agency working with social services, strengthening our Care Programme Approach standard operating procedure to ensure that there are robust timescales for the frequency with which such meetings should be held.
“We urge anyone needing support to call our Mental Health Crisis Line which is available 24 hours a day, seven days a week by calling 0800 953 0110.”
We’re here to help
You don’t have to suffer in silence if you’re struggling with your mental health.
Here are some groups you can contact:
Samaritans: Phone 116 123, 24 hours a day, or email firstname.lastname@example.org, in confidence.
Childline: Phone 0800 1111. Calls are free and won’t show up on your bill.
PAPYRUS: A voluntary organisation supporting suicidal teens and young adults. Phone 0800 068 4141.
Depression Alliance: A charity for people with depression. No helpline, but it offers useful resources and links to other information.
Students Against Depression: A website for students who are depressed, have low mood, or are suicidal. Click here to visit.
Bullying UK: A website for both children and adults affected by bullying. Click here.
Campaign Against Living Miserably (CALM): For young men who are feeling unhappy. There is a helpline: 0800 58 58 58 or visit the website.