The family of a mum and 17-year-old son who died within weeks of each have welcomed a coroner’s report to prevent future deaths.
Marshall Metcalfe died after suffering "catastrophic internal injuries" after falling from a building on 7 May last year.
Exactly a month later, his mum Jane Ireland was found dead at home after taking non-prescribed heroin substitute medication methadone, LancsLive reports.
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 4 unit The Cove in Lancashire prior to his death.
Jane Ireland was found dead a month after her son Marshall died
An inquest held over the last two weeks that concluded on Thursday ruled that Marshall's death was suicide.
Marshall had been seen at the top of the building where he fell to his death, the coroner said.
He said: ”Marshall is believed to have left his home on May 7, 2020, at 12 noon.
"Witnesses said his face was expressionless, blank and showed no emotion.”
Marshall died after falling from a building
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 Covid-19, only temporary barriers were put up which were then replaced with permanent fixtures – a month after Marshall’s death.
Expert witnesses 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.
Holly Ireland outside the coroner's court at Blackpool Town Hall
Earlier in the inquest, the coroner heard from Brendan Lee, the head of social service for children and social care at Lancashire County Council, who said the council had identified a number of areas for lessons to be learned following Marshall's death.
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, he said.
One expert witness described the lack of links between health and social care represented a "missed opportunity”.
Staff from The Cove sent a Section 85 letter to the council notifying them he had been discharged, but the letter was not passed on to social services.
Marshall subsequently went without support from social services for several weeks.
Despite some changes having been made at social services since Marshall's death, the coroner said he was concerned social services had not remained involved in his care after he was admitted to The Cove.
Marshall’s mum Jane Ireland, 44, died on 7 June 2020, a month after her son's death. The coroner returned a narrative conclusion in relation to Marshall's mum's death after ruling out suicide, misadventure or drug-related death.
The inquest heard that although she was struggling with Marshall's death, this was "not uncommon" and there was no criticism made regarding no action being taken after she disclosed her own suicidal thoughts.
Miss Ireland and her family moved from Burnley to Lytham in 2015 after her ex-partner bit part of her nose off.
During the inquest, her daughter Holly said this had had a massive impact on her mum.
"I was there when it happened," Holly told the inquest. "It had a massive impact on her. She just couldn't get her head round why he did it to her.
“I begged her to move away but she began to distance herself from her friends and started to communicate with angels. She relied on his family when he was in prison for what he did to her.
"She had no nose, she had to go through so many operations, and she found it so hard just walking through the streets looking like that.”
After the inquest, Holly said while she had hoped the coroner would highlight the failure to put up a permanent barrier at the building before her brother's death.
However, she welcomed the coroner's Prevention of Future Deaths Report relating to closer working between health care and social care.
At the conclusion of the inquest, the coroner said he intended to send a Prevention of Future Deaths Report to Gillian Keegan, the Minister of State for Care at the Department of Health and Social Care.
The Department of Health and Social Care will have 56 days to respond to the report.
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