The mother of a 17-year-old who died after falling from the top of a car park in Bury is calling for justice for her son - who had a history of mental health problems. Stanislav Mucha, from Bury, had been diagnosed with acute on-set psychosis after being sectioned under the Mental health Act in April 2020, but showed no indication of self-harm, Rochdale Coroners' Court was told.
Stanislav died on February 3, 2021 after falling from a car park the day before. He was transferred to Salford Royal Hospital, where he died as a result of 'polytrauma'.
The court was told Stanislav’s friends were concerned by his behaviour when the Covid lockdown was first announced.
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That, the court heard, was the start of a string of issues with his mental health. A lack of communication in the build up to his death was cited by senior coroner for Greater Manchester North Joanne Kearsley as an area of concern.
After being detained under the mental Health Act in April 2020, Stanislav had displayed psychotic symptoms such as hearing voices. A mental health act assessment should have taken place on January 22, but due to Stanislav’s apparent lack of cooperation it was postponed until the day after he died - something the coroner criticised as none of the staff members there tried to ask permission to enter the house.
Ms Kearsley said there was no explanation for why that was done - and why standard practice was not followed. Those issues will be included in a report which will look into ways the health services can prevent future deaths.
Speaking after the inquest concluded, Stanislav’s mother said: “I just want justice for my son. I believe more could have been done for him.
“All these children need help and these services should be speaking with them.
“They need to know what is happening with these children. If they did speak with my son, he would still be here.”
Stanislav had been refusing to take his medication or speak to mental health professionals psychiatrist Dr Stewart and care coordinator David Thomlinson since his return from Slovakia. This was a trip he took with his family, to their country of origin, and he had all the medication he required.
The coroner believed that the role of cannabis in his illness had ‘far too much emphasis’ placed on it. An example of Stanislav’s mental health deterioration during his three months in Slovakia, where he did not use the drug, was used as an example.
Timeline of events:
- 2019: Friends of Stanislav raise concerns about his behaviour
- Early 2020: Behaviour exacerbated by Covid lockdown
- April 2020: Parents recognise he needs help and Stanislav is sectioned under the Mental Health Act for several weeks
- During his time as an inpatient with Pennine Care NHS Foundation Trust at Fairfield Hospital he displayed psychotic symptoms
- May 26, 2020: Discharged from the Hope Unit and was passed into the care of the Early Intervention Team - Stanislav was no longer showing symptoms of psychotic behaviour and was responding to medication
- June 5: Allocated a care coordinator David Thomlinson and psychiatrist Dr Alistair Stewart
- End of June: Incident involving a young female and a mental health act assessment was done the next month following this behaviour, but he was not deemed to be detainable
- End of September 2020: Stanislav goes with his family to Slovakia with a supply of medication
- January 3, 2021: He returns to the UK unbeknown to social services and mental health services
- January 11: David Thomlinson visited Stanislav at home but he refused to speak to him and only saw him briefly. Stanislav's mother explained that he was not getting any better, was not taking his medication and did not want to see health professionals
- January 21: Stanislav missed his appointment with Dr Stewart, who then attempted to arrange a mental health assessment that day which he was not able to do as he was told to self-isolate with Covid.
- January 22: Four mental health professionals attend Stanislav's home address to conduct an assessment but cannot get him to engage, but made no attempt to go into the property, the court was told. Documentation of the events on this day was sparse and there was a concerning lack of communication, the coroner said.
- January 26: Having learnt of the outcome, or there lack of, on January 22, Dr Stewart arranges a fourth mental health assessment for February 3.
- February 2: Stanislav left his home address and headed towards the Rock Centre in Bury
- February 3: He dies in Salford Royal Hospital from his injuries as a result of the fall
“Having reached my findings I have to consider whether any of the failures caused or contributed to Stanislav’s death,” Ms Kearsley said summing up. “One of the striking features of Stanislav’s illness is that it did not present overt explicit risks of self-harm.
“His diagnosis would always give rise to some risk of impulsivity but he had no known attempts of self harm. He was not someone who expressed suicidal thoughts, albeit there had been no attempt to explore this since his return from Slovakia.”
Ms Kearlsey went on to say that whether the mental health assessment on January 22 would have led to Stanislav being detained is unknown, which means there is no evidence to say he would have been in hospital on the date of his death. When giving her conclusion the coroner was not satisfied that Stanislav intended the consequence of his actions and could not find any further evidence of suicide, so ruled that out.
Ms Kearsley gave a narrative conclusion: “He died as a result of catastrophic injuries sustained after he jumped from a sixth-storey car park. There was no evidence of his intentions and he had a history of psychosis.”
Clare Parker, executive director of nursing, healthcare professionals & quality governance at Pennine Care NHS Foundation Trust, said: “We offer our deepest sympathies to Stanislav's family for the loss of their much loved son and we are very sorry for what happened. We accept the conclusion of the coroner and we will learn from the recommendations made to us.
"We will be making improvements in how we work together with local authority teams to better help and support our patients.”
If you're struggling with your mental health or are in crisis, you can call Samaritans free of charge on 116 123 - they're available 24 hours a day, 365 days a year.
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