Prevention of Future Deaths Report: John Kirkman (16 July 2025)

Summary

John Michael Kirkman, aged 36 years, had a long history of paranoid schizophrenia which was difficult to control despite appropriate medication. He had a number of detentions and admissions pursuant to various sections of the Mental Health Act 1983. In the weeks leading up to his death, he is likely to have researched the toxicity of a product, and indeed, arranged for a number of packs of the product to be purchased on his behalf.

John was alive at 22.15 hours on 26 December 2023 and is likely to have ingested the product some time between then and 03:00 hours on 27 December. He is likely to have died around 07:51 hours on 27 December 2023. There was no realistic opportunity to have saved his life by the staff at the home. There were no suspicious circumstances or third-party involvement surrounding his death and the conclusion of the inquest was suicide.

Content

Matters of concern

Evidence was heard that if a mental health screening assessment is carried out in one part of the country, the results and conclusions reach may not necessarily be immediately available in another part of the country, when a further assessment is carried out. Evidence suggested that such assessments capture important clinical information and the lack of availability of preceding data may adversely influence subsequent assessments. Screening may form the basis for onward referral for formal mental health assessments. Absence of vital background information could result in an incorrect prioritisation for onward referral as it did in this case. The situation is not ubiquitous but does occur due to the use of different I.T. systems in various institutions.