Dan Kay spent his life helping others but was let down when he needed support

Dan Kay was the sort of person who always made other people feel like a priority. Whether it was helping his Liverpool ECHO colleagues, inquiring about their lives or visiting his many friends around the city whenever they needed him, he was as selfless as a person can be.

You only have to look at the relentless work he did to support the families of those who died at Hillsborough in 1989 to know that this was a man who dedicated his life to helping others. Sadly we now know that when Dan really needed help himself, the services he was relying upon fell short of what he required and of what he deserved.

Over three traumatic days at Liverpool Coroner's Court last week, Dan's friends, family and former colleagues heard of the numerous mistakes, communication breakdowns and failures that may have contributed to his tragic passing at the age of just 45.

READ MORE: Dan Kay remembered as 'selfless, caring man' who gave everything to others as inquest into his death concludes

READ MORE: Missed opportunities to prevent death of Hillsborough campaigner and former ECHO journalist

When Dan died, on May 7 last year, there was an outpouring of grief around Liverpool. He was known and loved all over the city he adored for his campaigning journalism, his pursuit of social justice and his kindness and charismatic personality. The fact that a person so dedicated to providing help and hope for others was denied those things in the lead up to his death feels particularly devastating.

The inquest into Dan's death was always going to be extremely difficult to listen to, to report on and to read about for those who knew and cared for him. But it is vital that lessons are learned from the mistakes that were made so that others don't suffer or slip through the net in the way that he did.

It was deeply frustrating for Dan's family and friends to hear in court how poor communication and record keeping from members of Merseycare's Crisis Home Resolution Team, as well as a lack of professional curiosity, meant no one explored why Dan, who had made two serious attempts on his life just days earlier, would potentially cancel a scheduled meeting on the day he died.

Members of the team admitted to 'huge mistakes' in terms of communicating and recording Dan's care plans and appointments, while it was revealed just one mental health practitioner had made a decision to reduce Dan's home visits, with no record of this significant change and no discussion with other members of the team. Listening to this evidence, the mood of frustration and anguish amongst Dan's family and friends in court was palpable. They could see the opportunities that were missed to protect him.

They also heard of worrying staffing shortages which meant on the night that Dan was assessed following a suicide attempt, there was just one mental health nurse in the entire Royal Liverpool Hospital who could perform that function and make a critical decision about whether he should stay in hospital or go home. She may have been able to contact a registrar but there was just one person on shift covering the whole of the city of Liverpool and up to Southport.

As the coroner made clear, no one working on Dan's care would ever have wanted this outcome and some of the witnesses who gave evidence were clearly distraught this week. But it is absolutely vital that those mistakes are addressed and learned from. Merseycare carried out an investigation after Dan died and told the court improvements have been made in terms of training, record keeping, senior staffing and processes when patients cancel arranged visits.

After the coroner's significant verdict that there was an arguable breach of the state's duty to protect Dan's life and of the mistakes that potentially contributed to his loss, Dan's cousin Amos, who has relentlessly and inspirationally fought for justice for Dan, spoke outside court of his deep frustrations - as well as his relief at the verdict delivered.

Mr Waldman said: "It's been incredibly difficult, it hit me today as the coroner made those findings. He said there were real possibilities. Anyone who heard what has come out of the inquest will think why did they do that? Why was he not admitted in the first place? Why with no record of any change in risk did they alternate him to visits every other day? It was incredibly frustrating that these opportunities were missed.

"We heard from the witness who assessed him at the hospital was the one qualified person at that hospital on that evening and when we talked about what she would do to escalate it, she could speak to one specialist psychiatric registrar on duty covering the whole of Liverpool up to Southport. She was essentially a psychiatric nurse placed as clinical lead and she had a huge responsibility and I have some sympathy for the lack of resourcing.

"But its It's clear from the community team that they weren't adequately qualified or resourced and there are major issues that need to be looked at. Dan should have been here now. We hope we can move on and hope that people will learn from this process."

Mr Waldman added: "For someone who spent his whole life campaigning for social justice it's right and fitting that he got justice himself."

Having achieved that justice and such a significant inquest verdict, Dan's family and friends will now move on to continuing his incredibly legacy through the Dan Kay Foundation, which is already raising huge sums of money for the causes he held dear - including mental health, spreading kindness and providing opportunities for the less fortunate.

One thing is for certain, Dan Kay's unflinching passion to support others and to fight against injustice will continue in his name and he will always be remembered as a selfless, kind and caring man who did so much for so many.

A Mersey Care NHS Foundation Trust spokesman said: “We are aware of the inquest into the death of one of our service users and would like to express our deepest sympathies to the friends, family and loved ones of the deceased at this difficult time.

“Mersey Care prides itself on being a learning organisation and routinely reflects on all our practices, but particularly after a tragic incident like this. Immediately after this incident we conducted a serious incident investigation and have updated our practices in line with recommendations from our internal review.

“We will continue to monitor our standards of care throughout our services. As a Trust we remain committed to the delivery of high quality care for all our patients, services users, carers and their families.”