Failures in communication between the police and ambulance service contributed to the death of a father-of-two from Bury St Edmunds, an inquest jury has concluded.
Mark Harris, 24, described by his mother as a ‘bubbly and hardworking man’ was found hanged at his ex-partner’s flat in College Mews, Bury, on January 11, 2016.
The inquest, which spanned nine days, heard his former partner Laura Manning called police at around 1.40pm on the day he died asking for the ambulance service to conduct a welfare check after telling them he had sent her text messages telling her he was going to take his own life and that they had her permission to force entry.
But despite a police officer and PCSO being sent at 2.20pm, as well as two ambulances being dispatched but diverted to other incidents, his body was not discovered until 5.20pm - three and a half hours after the initial call.
The inquest heard Mr Harris suffered long-term mental health issues and had been told by the Children and Family Court Advisory and Support Service on the morning of his death that visits to his children had been reduced to just six times a year.
Today the jury at Suffolk Coroners Court in Ipswich concluded his death was as a result of misadventure. They said Mr Harris had hanged himself but did not intend to die.
The jury identified failures in communication between the East of England Ambulance Service and Suffolk police that contributed to his death.
The jury said information - including Miss Manning’s name, number and that she had given permission to enter her flat - was not passed from the 999 ambulance call handler to the police control room and that further information which would have identified Mr Harris was not passed from the control room to officers at the scene.
They said the information would have meant police could have entered the flat at 2.20pm, just 40 minutes after receiving the call, adding Mr Harris’ death could possibly have been prevented.
They also said the ambulance service call handler should have asked Miss Manning to go to the property to let officers and paramedics in and that delays to ambulances diverted away from the scene also contributed to his death.
Area Coroner Jacqueline Devonish said she is writing a report to the services based on the findings.
Family statement
“Mark was a loving dad who would have done anything for his children, and a hard worker who, like many young men, had mental health issues.
“He was a good and very protective brother who loved both of his sisters very much.
“He was a loving and caring son, grandson and uncle, and is missed every single day.
“We as a family would like to say thank you to everyone that has been involved in the entire inquest process.
“From Joel and the IOPC team; to Ruth and Lochlinn for all their time and effort, the jury for their time and careful consideration of the case, as well as the coroner for all the work she has put into the process.
“Everyone’s assistance is much appreciated.”
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