Inquest rules death of Warrington mental health patient was contributed to by neglect
Liam McGenity was passed around various hospitals in the three months leading up to his death
Last updated 27th Feb 2024
An inquest into the death of a man who died in a mental health facility in Warrington has found his death was contributed to by neglect.
Liam McGenity from Widnes died on 2nd March 2021 whilst an inpatient at St Mary’s Hospital, a private facility run by Elysium Healthcare for men aged 18 and over.
Liam was admitted to St Mary’s in February 2021 following a mental health crisis and his bed was commissioned by the NHS. He was 29 years old at the time of his death.
An inquest jury has concluded there was a gross failure to provide basic medical attention
In its written conclusion, the jury found:
"Liam McGenity died as a result of suicide in the 2/3/2021
"Whilst located on the Eve ward Liam perceived interventions and restrictions to exacerbate his mental health presentation and therefore this could have probably contributed towards his death.
"Whilst located on Eve ward the manner in how 1-to-1 observations were carried out also contributed to the death of Liam.
"1-to-1 observations were carried out by a healthcare professional who stated that he understood the 1-to-1 work observation policy. The jury feel that the 1-to-1 observations were not carried out correctly and therefore contributed to Liam's death.
"There were no suggestions offered regarding staff having concerns about healthcare workers understanding of this role in carrying out 1-to-1 observations. However staff had observed a healthcare worker carry out poor practice in observations such as reading the newspaper.
"A nurse in charge claimed that a form of handover had taken place to the healthcare worker - one was observed carrying out observations on CCTV. The jury therefore feel there is evidence to suggest a handover was completed and this did NOT contribute towards Liam's death.
"The identified ligature point and risk associated - the ligature point should have been mitigated by correct 1-to-1 observations. It is possible that a reduction in Liam's medication contributed to his death.
"It is possible that the absence of psychological services contributed to Liam's death.
"Whilst at eve ward under section 3 of the mental health act, Liam was dependent on staff on the eve ward for his care and support needs.
"The jury feels that there was a gross failure to provide basic medical attention and therefore Liams death was contributed to by neglect.
"If the basic medical attention had been provided this would have probably prevented Liams death.
Liam’s family commented after the inquest concluded:
“There was no winning for us today, as nothing will bring our Liam back, but we are relieved that the jury came back with the most severe conclusion left open to them.
“We had hoped that St Mary's, owned by Elysium, would approach the inquest with honesty and openness to help make real change so this does not happen again.
"Instead, we have been shocked and appalled and made to feel they have spent all their time and money to approach the inquest defensively and have put all their efforts into hiding the catalogue of failings that they made. We feel hugely disappointed with them, and not at all confident that we'll see any changes to their practices.
“We are outraged by the presentation of the senior staff at St Mary's that we have seen in court, and feel like their 'care' is archaic, relying solely on force and medication as their only tool to help patients’ rehabilitation.
"They denied our Liam any visits from family, outside leave, meaningful activities or therapy from a psychologist, and isolated him in his room for 10 days, which left Liam with no other option.”
Prior to the inquest, Liam's family said he has such a bright future ahead of him:
"Liam talented musician, with such a bright future ahead of him. He was utterly hilarious, with boundless energy and a zest for life, living each day to its fullest. Spreading love and happiness with his caring, creative and confident personality.
"We are blessed to be left with his beautiful music; his meaningful lyrics, soulful voice and skilled guitar playing. There are many of his much-loved songs on various music streaming platforms that we encourage everyone to listen to."
Liam’s family have been represented by Kelly Darlington, Partner at Farleys Solicitors alongside Lily Lewis of Garden Court North Chambers.
Solicitor Kelly Darlington said Liam was somewhere he should have been safe:
“Liam's family have fought for three years for justice for Liam and to find out the full facts surrounding his tragic and preventable death.
"Their main aim throughout has been to ensure that the serious failings in Liam's care do not happen again and that changes are made by Elysium Healthcare to ensure other vulnerable patients like Liam are safeguarded from serious harm.
"The Jury's conclusion reflects what the family have believed since Liam died and they would like to thank the Jury for their detailed and powerful conclusion.”