An inquest jury has concluded that a young father “was not properly and adequately assessed and reviewed” and that “adequate and appropriate precautions were not taken to manage” his risk of suicide. TJ Pimm (30) was found at the foot of a multi-storey car park on 26 August 2016.

TJ had been diagnosed with depression and stress and made the subject of a community order in February 2016. He had problems with alcohol, and on 8 August 2016 was sectioned by British Transport Police having told staff at Romford train station that he intended to put himself under a train. He was assessed at the Lakes Unit at Colchester General Hospital the following day, but no mental illness was found and he was discharged.

TJ failed to appear for a court appearance on 23 August 2016 and was circulated as wanted on the Police National Computer, with warning markers on his log for mental health, depression and stress. A warrant was issued for his arrest.

At 17.13 on 25 August, TJ’s father telephoned Essex Police informing them that TJ’s whereabouts were unknown and that he had repeatedly threatened suicide, including the previous day. TJ’s father asked the police to do everything they could for him.

Police attended at the local probation office at 17.30 but did not locate TJ. Police made no further arrest attempt. It was accepted that TJ ought to have been categorised as a missing person rather than as a standard “arrest request” case.

That evening, his probation officer accompanied him to Accident and Emergency at Colchester General Hospital and he was seen by a mental health liaison nurse. TJ had told his probation officer that he had been to the top of a multi-storey car park and to Kelvedon station that day, contemplating suicide. TJ was not assessed or treated and advised to hand himself in to police where he could receive an assessment in custody. He returned home with his mother that evening.

The next day Mrs Pimm dropped her son in Colchester town centre so that he could hand himself in. He died a few hours later.

HM Senior Coroner will now consider whether any Prevention of Future Death reports are required. Jim Duffy had previously successfully argued that the inquest should be held under Article 2 of the European Convention on Human Rights (right to life) and that it should be held with a jury.

Jim was instructed by Emma Jones of Leigh Day. For further information, Leigh Day’s press release can be accessed here.