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

Missed opportunities in the mental health care of a respected Liverpool journalist - including issues around a cancelled home visit on the day he died - may have contributed to his death, an inquest has concluded.

A hearing at Liverpool Coroners' Court today made the significant finding that the Article 2 (the right to life) obligation under the European Convention on Human Rights was engaged on the basis that there was an arguable breach of the state’s duty to protect Dan Kay's life. Dan, 45, was a hugely popular former member of the Liverpool ECHO team and was known throughout the city and beyond for his pioneering journalism and for his tireless campaigning for justice for the victims of the 1989 Hillsborough disaster and their families.

Dan's achievements were even recorded in Parliament following his death last year. A three-day inquest at the Gerard Majella Courthouse in Liverpool today concluded with Coroner Joseph Hart recording a suicide verdict - that Dan took his own life on May 7, 2023 when he deliberately put himself in the path of a moving train close to Mossley Hill railway station.

READ MORE: 'Huge mistakes' in days leading up to death of much-loved former Liverpool ECHO journalist

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The inquest had earlier heard evidence that Dan, who had suffered with poor mental health for many years, had made two attempts to take his own life - on April 28, and again on May 1 last year. Following the May 1 attempt he was taken to the Royal Liverpool Hospital. After a mental health assessment it was decided he would be sent home, with daily visits from the trust's Crisis Resolution Home Treatment Team (CRHTT).

But the court heard that after four days these visits were reduced to every other day, with phone calls in between, with no rationale for this change included in Dan's notes. He was then due to be visited at home on Sunday 7, but this visit was cancelled by Dan. The reasons for this cancellation were not recorded or explained by the mental health team. This was the day that Dan took his own life.

In his conclusion today, Mr Hart said: "The lack of a visit on the day of Dan's death, in the absence of a visit in person the day before, could have had a real prospect of eventuating a different outcome. The absence of formal consideration of the support needs possibly contributed to Dan's death."

He added: "On balance, the failure to properly consider the impact of the missed visit was in my judgement a missed opportunity, which is a possible contribution to the ultimate outcome."

The coroner also spoke today of issues Dan was facing in terms of a rescue dog he had adopted in the January before he died. The inquest had earlier heard how the dog had arrived from Bosnia via an agency based in the UK but was in poor health and became very aggressive. Witnesses told how Dan tried to do everything to help the dog before being advised to have it put down.

After this, friends told the court that Dan received "malicious emails" from the company, including one from the dog's purported original owner in Bosnia which said: "You have murdered my dog". These experiences led to a dramatic decline in his mental health.

Mr Hart said today: "The circumstances in which the dog was adopted are troubling in terms of the impact of the circumstances on Dan, with him ultimately having to put the dog down. This should not be underestimated in terms of the harrowing impact it had on him and his mental health."

The court had heard earlier evidence of mental health workers admitting to "huge mistakes" in terms of failing to properly record notes around Dan's decision to cancel the planned visit on the day of his death, and regret at not exploring why he would do this. One mental health worker who had been due to visit him on the day he died said he was 'taken aback' to hear that the appointment had been cancelled.

On the final day of the inquest today, the court also heard from Ashlie O'Connor, the clinical services manager for Merseycare's Crisis Resolution Home Treatment Team, who was questioned about improvements made to the service following an investigation into Dan's death. She told the court that processes have been improved, including more than doubling the number of consultant psychiatrists in the team and ensuring that more senior figures are involved in making decisions about reducing the number of visits for a service user. In Dan's case this decision had been made by just one mental health practitioner.

She said the service has also increased the number of clinical leads it has, introduced a more robust process for dealing with referrals and brought in mandatory professional curiosity for all members of the CRHTT. Dan's family said they were disappointed that even at the inquest, Mersey Care NHS Foundation Trust maintained the position that Dan was not at any real and immediate risk of taking his life. The coroner commented in his ruling that there was an obvious real and ongoing risk of suicide to Dan which was abundantly apparent to all those who saw him.

During the inquest, the coroner made enquiries with Liverpool City Council about Dan’s ability to access the railway. This led to the immediate removal of street furniture near the railway fence.

Speaking outside court today, Dan's cousin Amos Waldman said: “For someone who spent his whole life campaigning for social justice it's right and fitting that he got justice himself.

“Dan was sadly troubled with poor mental health for much of his life. He was a much loved member of our family and it was extremely difficult to see and hear how much he suffered. His family and friends tried to give Dan as much help and support as we could, and to always encourage him to take the professional support that was offered by NHS mental health teams.

“However, we do feel that in the days before his death that Dan was let down by the team of people that was supposed to be there to give him the care and support he needed.

“It is disappointing that when it was known that Dan had made two recent attempts to take his own life, that the mental health team workers do not appear to have tried harder to be sure that Dan was safe. We don’t know why there was confusion about the May 7 visit, and why Dan went two days without seeing a professional. The failure to have made proper notes about something so crucial is very disappointing to us.

“Through the Dan Kay Foundation we will continue to seek change in Dan’s memory to ensure an improvement to the mental health services in our area. We will always remember Dan with love and he will always be in our hearts.”

Leanne Devine, partner at solicitors Leigh Day who acted on behalf of the family, said: “It has been a privilege to represent the family of Dan Kay at the inquest into his death. Dan knew the deep love of his family and friends and the absolute respect of his colleagues at the Liverpool Echo. Also, as a result of his journalism, he was held in great esteem by the Hillsborough community of families.

“It is a tragedy that someone who was so loved and respected in his personal and professional life, suffered so badly with poor mental health to the extent that it put his life at risk.

“It is a greater tragedy that errors were made by the team tasked with keeping Dan safe in days of crisis in early May 2023. The severity of the risk to Dan was not reflected in their careful note taking and attention to his safety.

“We welcome the coroner’s conclusion and thank him for the rigorous analysis of the events leading up to Dan’s death and the care Dan received from Merseycare NHS mental health teams. We trust that careful note has been taken of errors that were made so that they are not repeated in the care of others who face similar struggles with their mental health.”