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Inquest into vulnerable Devon man’s death finds major failings by police, ambulance and health services

A jury at the inquest into the death of Chang Somers, a 36-year old man from Plymouth who was found dead in August 2012, has found there were major failings by Devon and Cornwall Police, South West Ambulance Service and community mental health services.

Following a week long inquest held at Torbay and South Devon Coroner’s Court, the jury found that there was miscommunication by all authorities concerned, a failure to prioritise a 999 call by police and a lack of sufficient follow up as well as a lack of appropriate assessment of Mr Somer’s mental health condition.

Mr Somers, also known as Valan Pitts, was a vulnerable man who suffered from schizophrenia and had learning difficulties. He was found dead on 22 August 2012 in a garden in Paignton, Devon after being reported missing by his family when he failed to turn up for a family celebration. He was last seen on 25 July 2012.

Prior to his death he had expressed concerns about his own mental health and his wish to be referred to a local psychiatric hospital. His family who had become increasingly worried about his behaviour and his fears that people were attempting to assassinate him, had requested he be assessed under section 3 of the Mental Health Act but this was never carried out.

The inquest heard that in the run up to his death Mr Somers visited numerous friends in Plymouth with one calling the police requesting he be sectioned by mental health services. IPCC investigators reported that on the day he went missing Mr Somers himself was in contact with police six times.

A man matching Mr Somers description was seen taking pills and collapsing behind a tree in a garden in Paignton on 25 July. The witness called 999 and ambulance and police services were asked to attend. On arrival paramedics searched the area but were unable to find Mr Somers, discovering only empty medication boxes. Police never attended the scene.

The dead body of Mr Somers was found almost a month later in an overgrown area of the same garden where he had been seen.

The jury reached a verdict of accidental death and noted a number of failings by the authorities concerned, specifically that:

  • the 999 call was not sufficiently prioritised
  • a follow up search was not carried out by police, and, importantly
  • a lack of follow up by mental health authorities leading to Mr Somer’s not being appropriately assessed when it was clear his health was worsening

Jocelyn Cockburn and Trudy Morgan of Hodge Jones & Allen (HJA), the civil liberties law firm that specialises in actions against the police, represented Cynthia Somers, Mr Somers’ mother. The family are also being supported by the charity INQUEST and Jude Bunting of Doughty Street chambers acted for the family at the inquest.

The Somers family say: “Chang was a joker, he had an amazing laugh which made everyone want to laugh with him. He was kind and generous, and had genuine charisma which drew people to him. Sadly, we knew that he was struggling and might be a danger to himself so made a number of attempts to get help for him.

“We welcome the jury’s findings of accidental death and failings by all authorities involved. Moving forward, the authorities need to work together collectively to support vulnerable people so that no other family should have to go through this ever again. Attitudes towards people with mental health conditions need to change. One of the hardest things for us to come to terms with as a family is the fact that, because Chang’s body was not found for so long, we will never really know how he actually died. His death has saddened many and he will be truly missed.”

Solicitor Trudy Morgan says: “The inquest found that the failings of the authorities contributed to Chang Somer’s untimely death. Those failings included serious miscommunication by various authorities, the 999 call not being correctly prioritised, despite it requiring an immediate response as a risk to life. A follow up search was not carried out. Finally, a lack of follow up by mental health authorities led to Chang Somer not being sufficiently assessed when his health was worsening.

“Chang was a very vulnerable man who did not get the help he needed. The family want to ensure that lessons will be learnt and that authorities implement real and lasting changes as a result of this conclusion.”

All press enquiries to:

Louise Eckersley, Black Letter Communications on 0203 567 1208, email:
Paula Knight, Black Letter Communications on 0203 567 1208 or 07776 230253, email:
Notes to editors:

Hodge Jones & Allen (HJA) was founded in 1977 in Camden and has 200 staff based in Euston NW1. The firm practices personal injury, clinical negligence, civil liberties, family law, wills and probate, housing, dispute resolution, criminal defence and serious fraud.

The Civil Liberties team at Hodge Jones & Allen is one of the UK’s foremost teams in bringing actions against the police and state authorities for deaths in custody. The firm’s solicitors work closely with INQUEST, which works for truth, justice and accountability for families, and campaigns for policy change at the highest level.

Jocelyn Cockburn is a leading civil liberties lawyer. She represents many individuals who have actions against the police, including: Neville Lawrence, the father of murdered teenage Stephen Lawrence in various ongoing inquiries into the conduct of the London Metropolitan Police and has acted for several families whose loved ones have died in Colnbrook and Harmondsworth Immigration Removal Centres. She has also represented the Pilkington family against Leicestershire Police Force’s failure to protect Fiona Pilkington, who killed herself and her severely disabled daughter in 2007 after years of torment by youths.

Prior to joining HJA Trudy Morgan worked in the Attorney General’s private office for three years. She now undertakes a variety of actions against public authorities, including civil claims against the police, judicial review, Human Rights Act and discrimination claims, as well as acting for bereaved families in inquest proceedings and related civil claims.