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Inquest jury concludes precautions to manage risk were not taken ahead of Terence Pimm’s death

The inquest into the death of Terence Pimm, known as TJ, concluded today at Essex Coroner's Court

TJ Pimm

21 April 2017

An inquest into the death of 30-year-old Terence Pimm, known as TJ, has concluded that his risk of suicide was not properly and adequately assessed and reviewed and that adequate and appropriate precautions were not taken to manage his risk of suicide.

TJ was found deceased at the foot of a car park in Colchester on 26 August 2016. 
The inquest was opened on Tuesday 18 April 2017 at Essex Coroner’s Court. During three days of evidence, the Court heard that TJ had been diagnosed with depression for a number of years and had been made the subject of a community order in February 2016. His mental health had declined in the months leading up to his death and he had problems with alcohol. 
On 8 August 2016, TJ was sectioned by British Transport Police under s.136 of the Mental Health Act after he threatened to take his own life at Romford Railway Station. He was taken by ambulance to Goodmayes Hospital, Ilford, before being transferred to the Lakes Unit at Colchester General Hospital. TJ was assessed the next day by an approved mental health person and a psychiatrist, who did not identify any mental health issues. He was discharged after twelve hours. 
TJ failed to appear for a bail hearing at Highbury Magistrates Court on 23 August 2016. He 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.
On 25 August 2016, TJ's father telephoned Essex Police to inform them that TJ’s whereabouts were unknown. He told the call handler that TJ was suicidal and had threatened to kill himself the previous day.
That evening, TJ attended an appointment with his probation officer and told her about his suicidal thoughts. She took him to the Accident and Emergency Department at Colchester General Hospital. TJ was seen by a mental health liaison nurse, but was not provided with a Mental Health Act assessment. 

Attempts were made by TJ's mother to contact Essex Police after leaving hospital but TJ returned home that evening without receiving any treatment. Tragically, he took his own life the next day. 

The Coroner stated that following the conclusion of the inquest, she will consider whether to issue Prevention of Future Deaths reports.

Karon and Terence Pimm, TJ's parents, said: 

“We would like to thank the jury for their thoughtfulness and consideration in listening to all the evidence and reaching their conclusion. We would also like to thank the coroner for the fair and balanced inquest.
“We wish to express our appreciation to NHS and police witnesses for their honesty and openness in giving evidence.
“Before this conclusion we felt guilty that TJ’s death was our fault but through the inquest we realised that the various services that TJ came into contact with, and who we contacted ourselves to ask for help for him, should have been able to offer him the valuable support he needed but failed to do this. Now we know that we tried to get him help and couldn't get it.
“We are grateful to our legal team from Leigh Day and counsel Jim Duffy for their help, support and guidance - without them would never have got this conclusion.”
Emma Jones, Partner in law firm Leigh Day's Human Rights team, said:
“We welcome such a full and thorough investigation and we hope that through this process we have identified areas of concern that need to be addressed to ensure the failure of support faced by TJ does not happen again.”

TJ's family were represented at the inquest by Emma Jones of Leigh Day and Jim Duffy of One Crown Office Row.

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