Inquest rules 'adequate precautions' were not taken ahead of Dovercourt man's suicide
PUBLISHED: 19:50 21 April 2017 | UPDATED: 20:07 21 April 2017
An inquest into the death of a Dovercourt man who jumped from the top of a Colchester car park has ruled "adequate and appropriate precautions" were not taken ahead of his suicide.
Terence Pimm, 30, jumped from the seventh floor of the NCP car park in Osborne Street on August 26 last year and was pronounced dead at the scene.
A jury at Essex Coroner’s Court recorded a narrative conclusion that his risk of suicide was not properly and adequately assessed and reviewed, and that adequate and appropriate precautions were not taken to manage his risk of suicide.
During the four-day inquest, the court heard how Mr Pimm, known as TJ to his family and friends, had problems with alcohol and had been diagnosed with depression.
On August 8 – less than three weeks before his suicide – Mr Pimm was detained under the Mental Health Act after he made threats to kill himself at Romford rail station.
He was assessed at the Lakes mental health unit in Colchester, run by the North Essex NHS Foundation Trust, and was released the following day.
Nusrat Baloch, the doctor who assessed Mr Pimm, told the court he was “spontaneous, cooperative and open” and that there was “no evidence of mental illness” during the assessment.
The day before his death, an arrest warrant was issued for Mr Pimm for failing to appear at magistrates’ court on August 23, and Mr Pimm’s father telephoned Essex Police to inform them that his son’s whereabouts were unknown and he was suffering from drink and drug abuse.
He also told the call handler that his son was suicidal and had made threats to kill himself.
The same day Mr Pimm admitted to a probation officer at an appointment that he had been at Kelvedon train station and at the top of the NCP Osborne Street car park contemplating suicide.
Elana Snowling, of the Essex Community Rehabilitation Company, formerly Essex Probation, took Mr Pimm, who had been drinking, to the A&E department at Colchester General Hospital.
At the hospital he was seen by Angela Rooke, mental health liaison nurse, who told the court she twice offered Mr Pimm the chance to stay overnight and be fully assessed in the morning.
He went home with his mother that evening but took his life the next afternoon and was pronounced dead at 1.16pm.
Speaking after the inquest, Mr Pimm’s parents, Terence and Karon, said: “Before this conclusion we felt guilty that TJ’s death was our fault but through the inquest we realised that the various services that TJ came into contact with, and who we contacted ourselves to ask for help for him, should have been able to offer him the valuable support he needed but failed to do this.
“Now we know that we tried to get him help and couldn’t get it.”
Emma Jones, partner at Leigh Day, representing Mr Pimm’s family, said: “We welcome such a full and thorough investigation and we hope that through this process we have identified areas of concern that need to be addressed to ensure the failure of support faced by TJ does not happen again.”
A spokesman for Essex Police said: “This is an extremely sad case and our sympathies remain with TJ’s family and friends.
“We set the highest of standards in how we deal with and treat very vulnerable people and officers and staff are trained in dealing with mental health issues.
“We work daily with mental health professionals to make sure our response to these incidents is professional and proportionate.
“One example of this is our mental health triage car which means officers have direct contact with mental health professionals at the scene of an incident so the support and care can begin as early as possible.
“In cases such as this we will always look to learn about how we might be able to adjust or improve our policies or processes in future.
“We’ve looked at how calls are classified and how calls made directly to custody are handled. We’ve also looked at our missing persons policy to make sure all staff are aware of how the policy works and what their responsibilities are.”
The North Essex Partnership NHS Trust, now the Essex Partnership University NHS Foundation Trust (EPUT), were contacted but have not currently responded.
Senior Coroner for Essex Caroline Beasley-Murray told Mr Pimm’s parents: “Not only have you lost a much-loved son and family member, you also had the ordeal of sitting through this inquest and you have done that with dignity.
“The court would like to express sympathy for TJ’s loss.”