A delay by police in re-grading the severity of the case of a man who said he intended to take his own life - before he was found unresponsive at his home - 'possibly' contributed to his death, a coroner has concluded. Jordan Peter Clare, 22, died on August 28, 2020.
He was found hanged at his home in Marple, Stockport, and sadly passed away at Stepping Hill Hospital two days later. Manchester South Coroners' Court heard that on August 26, he was in a 'state of agitation and frustration' about the 'apparent lack of progress' in a dispute with a neighbour being resolved.
Documents relating to the coronial hearing state Mr Clare - who had diagnoses of ADHD; attachment and conduct disorder; and anxiety and depression - 'intimated an intention to take his own life in the context of the neighbour dispute to a police call handler'.
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The call to police, the hearing was told, was made at 10.57am. The call handler then contacted Mr Clare's housing support worker at Stockport Homes Group and informed her of the content of the call, but failed to record any reference to the threat of self-harm in the police log, a record of inquest in the case states.
Mr Clare had contact with other agencies and members of his family after that call, the court heard. He did not indicate 'any similar intention' in those exchanges.
He sent messages to his support worker between 12.38pm and 12.44pm, in which he 'explicitly indicated an intention to hang himself when he arrived home', papers state. Mr Clare repeated those threats when the support worker contacted him shortly afterwards by phone.
Police were then alerted by the support worker. Officers were sent to Mr Clare's home. Coroner Adrian Farrow wrote: "Th ere were missed opportunities to initiate consideration of regrading the incident and a delay in the process of regrading the incident to immediate response status (Grade 1) until 1.06pm."
Cops broke down his door at 1.20pm and he was found hanged. Mr Clare sustained hypoxic brain injury, from which he died at Stepping Hill two days later.
Mr Farrow wrote: "The accepted failing of the police to record the intention to take his own life following the call at 10.57am reduced the body of available information, but was not causative of his death, but the delay in regrading the incident to Grade 1 as a result of the call made by the support worker at 12.44pm possibly contributed to the death."
The coroner concluded Mr Clare's death was a case of misadventure, in relation to distress over an 'unresolved housing issue'.
Following the conclusion of the case, a statement released on behalf of Mr Clare's family read: "Jordan had struggled since he was a child with ADHD and ODD. Eventually, he turned to drugs to help deal with his intense difficulties. But while he was in prison he was able to stop using the drugs and we really felt he had turned a corner and had hope for the future.
"We were so proud of him for coming off the drugs, and he said he wanted to sort his life out so that he could make us proud. Jordan desperately needed support, but we feel it just wasn't there for him.
"On August 26, he was crying out for help. We wish people had listened. We think if Jordan had got the help he needed, he would still be here today. We are glad that the coroner has heard what happened with Jordan and that the issues that caused him such pain have been made clear."
A spokesman for Greater Manchester Police said: "Firstly, our thoughts remain with Jordan Clare's loved ones who will, understandably, be devastated by his death.
"GMP is committed to responding to incidents and emergencies, and keeping people safe, particularly vulnerable people. This commitment has already informed changes to our Force Contact Centre.
"We are in receipt of the coroner’s findings and it would be inappropriate to comment further at this time."
A spokeswoman for Stockport Homes Group said: "Our condolences are with Jordan's friends and family at this difficult time."
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