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Inquest into the death of mental health patient Darian Bankwala concludes at Chelmsford Coroner’s Court

In a narrative conclusion, the coroner stated Darian’s “discharge should have been managed in a more professional and thorough way” by EPUT staff

The inquest into the death of 22-year-old Darian Bankwala has concluded. The 8-day inquest began on Wednesday 23rd March 2022 and was held at Chelmsford Coroner’s Court. The family were represented at the inquest by Turan Hursit (counsel) of Old Square Chambers and Hodge Jones & Allen.

Darian Bankwala, the youngest of five brothers, was born and raised in Chelmsford, Essex. Darian had learning difficulties and some autistic traits which were never properly investigated or diagnosed. Darian coped reasonably well at primary school but began to struggle at the start of secondary school and his mental health began to deteriorate.

After Darian left school at 16, his mental health stabilised and he was able to attend and enjoy college. As Darian approached the end of his time at college, his mental health declined again. Although he successfully obtained a job at Domino’s pizza, he struggled to cope and unfortunately had to leave.

Darian’s mental health continued to get progressively worse until in February 2020 Darian’s parents were able to convince him to see a mental health nurse at Chelmsford Hospital. Despite his parents raising concerns and Darian showing warning signs of suicidal behaviour he was not admitted for treatment. Instead he was advised by a senior medical practitioner to self-treat at home, with little to no professional guidance as to what this treatment would involve. A few days later, after Darian was taken to A&E, he was admitted to Southern Hill Hospital in Norfolk, under section 136 of the Mental Health Act 1983. Shortly afterwards, he was relocated to the Linden Centre.

At the Linden Centre, Darian’s mental state further deteriorated. Despite this, he was given one hour of unescorted leave per day yet he frequently stayed on leave for longer and absconded several times.

In April 2020, Darian was transferred to Rochford Hospital under section 17 of the Mental Health Act 1983 where he continued to receive unescorted leave, subject to a medical professional’s approval.

Darian’s condition continued to deteriorate. Despite this, the 22- year-old was discharged on the 7th of July 2020 without any discussion with his family.

Darian was provided with a care-coordinator but his mental health deteriorated further whilst in the community. The family made his care-coordinator and the Essex Partnership University Trust repeatedly aware of the situation but the support provided to them was limited.

On 27th December 2020, 4 months after his discharge from Rochford Hospital, Darian Bankwala got dressed and left his family home at midday and, tragically, was hit by a train at Wickford Station, close to his home, at 4:42 pm.

Whilst the Coroner did not make causative findings on the balance of probabilities, he expressed concerns about a number of points in his factual findings.

First, the Coroner found that mild learning disabilities and autism were inappropriately excluded from Darian’s differential diagnoses during treatment.

Second, it was considered concerning that “someone with such vulnerability could be discharged to a destination unknown with the presumption that his family would take him back in”.

Third, there was a “disproportionate, unnecessary, and helpful fixation from clinicians and ward staff” on unsubstantiated substance abuse/drug-induced psychosis, ultimately leading to a final diagnosis of “mental and behavioural disorder due to multiple substance misuse”, which “[did] not accurately reflect the uncertainty or breadth of differential diagnoses that had been identified under section”.

Fourth, it was found that some of the comments made about Darian at multi-disciplinary meeting level were “so out of keeping with any of the evidence…seen and heard that [they indicated]…a degree of malice on the part of those in the discussion” and suggested that the ward was “united in finding Darian to be something of an irritant”.

Finally, the Coroner expressed that “discharge should have been managed in a more professional and thorough way with clear lines of communication and much clearer lines of involvement. [The professionals] should at least have given opportunity for consideration of deferred discharge [of Darian] as a voluntary in-patient”.

Darian Bankwala’s father, Kobad, stated in evidence: “I had predicted that something like Darian’s death would happen, and I fought bitterly to prevent what ultimately did happen. It was a nightmare to get him into the system, it was a nightmare when he was in the system, it was a nightmare to stop him being released from the system and it was a nightmare after he was released. We now have another form of nightmare which will remain with us for the rest of our lives.

“We were a strongly knit family, always unified. Sadly, Darian’s death has destroyed the fabric of my family. It has changed all of our lives forever. Christmas and New Year will never be the same for us again. Darian has been stolen from us, from me and it need not have happened. As one of the nurses who looked after Darian at Southern Hill Hospital said to me, ‘what a waste of a young life’.”

Nina Ali, Partner at Hodge Jones & Allen, representing the Bankwala family said:  “The Bankwala family remain distraught by Darian’s loss. Sadly, have seen countless cases such as this involving EPUT, and they are concerned as to whether lessons will be learnt. This case is sadly the most recent endorsement of the need for a full Statutory Public Inquiry into mental health care in Essex. The current inquiry has limited legal powers and scope and there are root and branch issues that must be investigated and understood. The family are devastated and torn apart by this tragedy that which they believe could have been prevented had the Essex Partnership University Trust provided an adequate care for Darian’s mental health.”