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Jury Finds Serious Failings In The Death Of Michael Nolan Who Died Hours After EPUT Team Claimed He Was “Very Happy”

Michael Nolan, 63, from Essex, died while he was an inpatient at Basildon Hospital, under the care of the Essex Partnership University Trust (EPUT) psychiatric team

A jury has today found serious failings in the death of a 63-year-old man who died under the care of EPUT, after being admitted to Basildon Hospital, following a previous attempt to take his own life. The inquest, conducted by coroner Sean Horstead, saw the jury deliver a narrative verdict which found that there were “serious failures” regarding patient observation, with the jury also highlighting that “if the observations and engagements had been carried out correctly, there may have been a different outcome”. In addition, the jury also stated that there were “serious concerns regarding the roles and responsibilities of the staff” during the night shift of Michael’s death.


Michael Nolan worked as a warehouse operator and was a member of the local working men’s club for over 30 years. Michael was married to Janice for over 38 years and had a son called James. He seemingly lived a quiet life with a strong support network around him, however, Michael started to show signs of poor mental health following the passing of his mother, which led to him struggling to sleep and having a more volatile mood.

On 22 June 2022, Michael attempted to take his own life by stabbing himself using a sharp knife. Michael was subsequently taken to Basildon Hospital to care for his wounds, where he was placed under the care of EPUT after being detained under Section 2 of the Mental Health Act.

During Michael’s admission, he was initially on constant one-to-one, level-three observations before being moved down to level two (where he was supposed to have four physical observations and engagements within an hour). The purpose of the observations was to check on Michael’s mental well-being following his attempt to take his own life.

On 10 July 2022, whilst under level two supervision, Michael was found unresponsive and not breathing by staff, and he eventually passed away later that day. Investigations later revealed that Michael had swallowed the lid of a roll-on deodorant bottle to take his own life.

During his time in the Kelvedon ward at Basildon Hospital, EPUT staff characterised Michael as “very happy” and “chirpy”, just hours before his death.

Statutory Inquiry

Michael’s tragic death adds to thousands that have occurred on mental health wards across Essex due to be investigated by the Lampard Inquiry. Chaired by Baroness Kate Lampard, the inquiry was upgraded from an independent inquiry in October 2023 after years of campaigning by Essex families led by Melanie Leahy. However, bereaved families have continued to wait for the Inquiry to begin since that milestone, with the Terms of Reference still to be agreed by the Health Minister.

James Nolan, Michael’s son, said: “I am grateful for the outcome of my father’s inquest. I have been in a state of shock since his passing. He should not have been able to take his own life whilst he was under EPUT’s care. He was meant to be in the safest possible place for him, and yet, he has been taken from us. I have lost faith in EPUT as an institution, and I hope that my father’s case will be a stark reminder of how bad things are and how much work needs to be done before we can trust EPUT to adequately care for our loved ones in their time of need.”

Priya Singh, Solicitor at Hodge, Jones & Allen said: “We welcome the outcome of Michael’s inquest. Until the Lampard Inquiry begins, we are locked in a perpetual battle with EPUT to get justice for those it has failed, as it continues to be inadequate at providing the most basic level of care to vulnerable people. We will not stop fighting until the death count stops going up and we will continue to remind EPUT of the categorical failures and expose attempts to brush this to one side. Let Michael’s passing be another reminder of how far we still need to go before we can ensure safety for our most vulnerable members of society.”

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