Liam McGenity: Inquest concludes neglect contributed to self-inflicted death

28 February 2024

This article is taken from the original report written by Farleys, which can be found here.

The inquest into the death of Liam McGenity took place between 19 February- 26 February at Cheshire Coroner’s Court in front of HM Area Coroner Victoria Davies sitting with a jury.

Liam McGenity died on 2 March 2021 whilst an inpatient at St Mary’s Hospital, Warrington, a private mental health facility run by Elysium Healthcare for men aged 18 and over. Liam was admitted to St Mary’s Hospital 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.

After seven days of evidence, the Jury have returned a conclusion that Liam’s death was contributed to by neglect.

Liam was sectioned to St Mary’s Hospital under Section 3 of the Mental Health Act and was dependant on staff on the Eve Ward for his care and support needs. The Jury recorded that there was a gross failure to provide basic medical attention and, had this been provided to Liam, this would have probably prevented his death.

In reaching their conclusion, the Jury recorded a number of failings on the part of St Mary’s hospital, run by private healthcare provider Elysium Healthcare. These failings included:

1. The identified ligature point and risk associated with the ligature point should have been mitigated by correct 1:1 observations
2. It is possible that the absence of psychological services contributed to Liam’s death
3. The manner in how 1:1 observations were carried out contributed to his death
4. 1:1 observations were not carried out correctly and therefore contributed to Liam’s death.

Liam’s family commented;

‘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.’

The family’s legal representatives, Kelly Darlington, Partner at Farleys Solicitors and Lily Lewis, of our Inquests and Inquiries team, commented;

‘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.’

Selen Cavcav, Senior Caseworker at INQUEST, said:

‘Liam’s preventable death under the care of the private provider Elysium is not the first one, and sadly will not be the last.  How is it that the same basic failures can be identified inquest after inquest with no proper oversight or learning?   

‘The jury’s powerful conclusion is another stark reminder of the dangers of outsourcing the mental health care of vulnerable people to unaccountable private institutions.’