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Two-week jury inquest into the death of a man who suffered from Asperger’s Syndrome and Paranoid Schizophrenia who was detained under the MHA. He died in a fire which he started whilst he was on unescorted leave from a psychiatric hospital. The conclusion was suicide.

The inquest explored multiple issues, including: (i) the assessment and management of his risk of self-harm / suicide (including identifiable triggers from his past history and during his latest admission to hospital); (ii) the communication of risk information between staff and different wards; (iii) whether he should have been allowed unescorted leave; and (iv) the adequacy of services available for patients with such a dual diagnosis. See media here.