Coroner rules health trust errors contributed to death of Adam Smith

During an inquest into the death of devoted dad-of-two, Adam Smith, from Great Sankey, a coroner ruled that mistakes made by Mersey Care NHS Foundation Trust contributed to his passing.

Adam, 30, whose body was found at Fiddlers Ferry, died as a result of drowning after he began suffering a period of paranoia and climbed into a storm drain at the site, a coroners court heard.

The inquest into the death of Adam, who has links to St Helens, concluded on Friday (April 19) after evidence was heard from his family members, police officers, and health professionals regarding his ongoing battle with mental health which led to his eventual disappearance.

A missing person appeal and police search which lasted more than two weeks concluded with the police discovering Adam’s body at the Fiddlers Ferry site on February 12, 2022.

And it was heard at Cheshire’s Coroners Court last Friday that Adam, whilst experiencing a period of paranoia, had climbed into a storm drain that went below ground at the Fiddlers Ferry Power Station and drowned. It is believed Adam first lost consciousness due to a lack of oxygen in the drain and went under the water.

Adam Smith (Image: Supplied)
The inquest heard how Adam was suffering a mental health crisis, and was displaying signs of psychosis, when he was discharged on January 27, 2022 by a mental health team managed by Mersey Care NHS Foundation Trust, at the Royal Liverpool Hospital, at 3am barefoot and return to his family home by police.

An appointment with his community mental health team, that was scheduled to take place at the home he shared with his mother Joanne Shillcock, and step-father Colin Shillcock at 2pm that day, was also cancelled without warning by Mersey Care staff.

While giving evidence, Colin and Joanne stated how they had contacted Mersey Care and described the deterioration in Adam’s mental health and his paranoia, and desperately tried to get the appointment reinstated.

However, they were told the best that could be offered was an appointment the following day.

By the time they got off the phone Adam had disappeared, and his family never saw him alive again.

Adam was missing for 17 days until he was found and there was an intensive search because of his vulnerability.

Recording a narrative conclusion, coroner Charlotte Keighley said that a plan to discharge him by Mersey Care NHS Foundation Trust was “not safe in practice”.

She found that the outcome of the Mental Health Act assessment undertaken before his discharge, would likely have been different, had it not been based on inaccurate information, and had the clinicians been aware of Adam’s history.

Adam Smith (Image: Supplied)
Coroner Keighley confirmed that these mistakes contributed to Adam’s death.

Speaking on the conclusion of the inquest, Adam’s mum Joanne said: “Adam was much loved by all the family, he was a devoted father of two young girls, and we remain devastated by his death. Not a day goes by when we don’t think of Adam, and all we have ever wanted is to find justice and answers for him and his daughters, who now have to grow up without a father.

“We welcome the coroner’s conclusion, which we believe is the right one. We fully believe that Adam would have gotten better with the right mental health support, but this was sorely lacking.”

Rebecca Cahill, a medical negligence solicitor at JMW who is handling the family’s legal case against Mersey Care NHS Foundation Trust, added: “The inquest has been a harrowing process for Adam’s family, and they have had to hear distressing evidence about his final days and the missed opportunities to help him.

“I will now be working with Adam’s family to take legal action against Mersey Care, which needs to be held fully accountable for its failures, in order to prevent another death like Adam’s.”

Mersey Care NHS Foundation Trust have been contacted for comment.