David Illingworth represents family of man who died by suicide, contributed to by neglect
September 11, 2025
David Illingworth from Exchange Chambers, instructed by Hudgell Solicitors, this week represented the family of a man who sadly died by suicide in a Blackpool Victoria Hospital A&E toilet – 22 hours after being admitted following a previous suicide attempt – at the Inquest into his death.
On the evening of 17 August 2024, Jamie Pearson (27) admitted himself into Blackpool Victoria Hospital, having taken an overdose of painkillers and attempted to ligature.
Despite this, he was deemed ‘low risk’ in the A&E department and transferred to a ‘fit to sit’ waiting area, where he was treated with fluids to prevent possible liver damage.
An Inquest at Blackpool Coroners Court this week heard that, due to a communication breakdown, plans were not made for mental health specialists to see him as a priority.
Having not been seen by any mental health specialists, despite having been at the hospital for 22 hours, Jamie locked himself in a disabled toilet. He was found in cardiac arrest 23 minutes later.
Jamie had used his own clothing to make an improvised ligature. He suffered hypoxic brain damage and very sadly died on 22 August 2024.
Jamie’s mother, Julie Knowles says he was let down in a ‘period of crisis’. She said:
“What I will never get over or be able to forgive is the complete disregard for Jamie’s well-being in a period of crisis.
“He had driven himself to the hospital as he knew he was suffering a mental health crisis and he wanted help and wanted to get better. He had so much to live for.
“You expect medical professionals to instantly recognise when somebody requires immediate, specialist help, but he was largely ignored… he was left alone with all those dark thoughts in his head.”
Senior Coroner Alan Wilson concluded that Jamie died of suicide, contributed to by neglect.
He said that the cumulative effect of the missed opportunities to provide Jamie with the care he needed “very comfortably” crossed the high threshold required for a finding of neglect.
He found that had Jamie been given appropriate care, he wouldn’t have died when he did, highlighting the general confusion as to whether he had been referred to see the specialist mental health team.
He added that, if staff assumed that Jamie’s medical needs had to be dealt with before attending a mental health appointment, they had been wrong, and that a number of failures in care had left Jamie vulnerable, and contributed to the steps he then went on to take.
He also found that the failure to act upon his attempt to ligature before attending at A&E had been a further ‘gross failure’.
David’s instructing solicitor Amy Rossall, of Hudgell Solicitors, represents Mrs Knowles and says a civil legal case is now likely to be pursued as the Inquest identified a ‘string of failings and missed opportunities which led to Jamie not being adequately assessed and treated’ when in hospital. She said:
“This is an exceptionally tragic case. Lessons may now have been learned as a result, but that is little consolation to Jamie’s mother, who believed at the time that he was in safe hands and in the best place given the fragility of his mental state.”
