Death of 'loving' 28 year-old dad, from Bewsey, ruled suicide

An inquest opened into the sad death of Nathan Cunliffe who was struck by a train on Alder Lane after fleeing Hollins Park Hospital on January 11, 2022.

Nathan, 28, was receiving care in the Austen ward of the NHS hospital in Winwick at the time of his death, having been admitted following a deterioration of his mental health.

And concerns relating to risk assessments and staff ratios at Hollins Park were raised as issues during the three-day inquest that took place at Cheshire Coroners’ Court in Warrington starting last Monday, February 5.

Nathan’s partner, Lauren Sayburn, spoke of her partner’s tough upbringing and what an ‘amazing’ dad he was.

Lauren said: “Nathan was the best dad to our two boys, and it still upsets me that they have to grow up without him by their side.

“In the two years before his death, Nathan’s mental health deteriorated, and it was awful to see him struggle how he did.”

A coroner’s court heard how Nathan was born in Warrington on August 11, 1993. At 15 he was homeless and sleeping on friend’s sofa’s, Lauren explained.

The trained nurse told how the pair met at a hostel in Latchford, describing Nathan from the outset as ‘timid and shy’, and their relationship blossomed from there.

A tipping point in the dad-of-two’s metal health first came when his mum disappeared, and he lost contact with her.

Shortly after, Lauren fell pregnant with their eldest boy, now 12, and she described how ‘supportive and loving’ Nathan was both during the pregnancy and as a dad.

It was said that Nathan would have periods where his mental health would deteriorate, with one particular incident being when he went missing from the family home and turned up in the kitchen holding a knife.

The police were called, and he was arrested, he had no memory of the event happening the following day and this led to him serving four months in prison. Lauren said despite this, they moved on and lived a happy family life together.

After giving birth to their second child, now aged six, Lauren said Nathan’s mental health suffered another blow and they began living separately while still continuing their relationship.

She detailed how when her partner was having a bad day, he would sometimes threaten to kill himself.

On one occasion in the lead up to his death he went missing for four days and turned up at her home ‘covered in blood’. She sought him an appointment at his local GP where he was admitted to Wakefield House, a mental health service at Warrington Hospital, but he was later discharged.

A further missing persons appeal was launched by Cheshire Police on December 23, 2021 for Nathan.

The inquest was held at Cheshire Coroners Court in Warrington (Image: NQ)

He was spotted on December 30 having been sleeping rough under a bridge, Lauren said.

After this incident, Nathan was admitted to Hollins Park facility.

“When he was admitted to the mental health unit, I really hoped and believed that was the start of him getting better and he would be back with us,” Lauren added.

The court  heard how the dad was unwell and obsessed with the numbers 666 and believed that bad things were going to happen to him. He would fluctuate between this state of mind and a positive mindset of getting better and his future outside the facility with his family.

Lauren recalled the night before Nathan’s death, having had a video call with him to which she noted he was in a ‘low mood’.

On January 11, Nathan made a bank transfer of £100 to Lauren’s account and sent a message telling her he loved her and the kids.

He escaped from the facility having jumped over a ten-foot fence in the walled garden area at approximately 5pm and Cheshire Police were alerted to the situation at 5.10pm.

In the initial response call logged, information was relayed to officers incorrectly that Nathan had left the building from the front entrance and had turned left. Officers then, with the help of sniffer dogs and drones, conducted a thorough search of the area.

Upon returning to Hollins Park with no trace of Nathan, officers were informed by staff that their information was incorrect, and he had left over the back fence of the hospital.

A further search was conducted before it was confirmed by British Transport Police that Nathan had sadly been hit by a moving train on Alders Lane.

Sgt Philip Pickering who attended the call at Hollins Park on January 11 highlighted in his statement that a hospital member of staff had stated in the garden area where Nathan had absconded from there was a gate that had been used previously by residents as a ‘stepping point’ – an issue that members of staff had raised.

The same individual had also confirmed this was not the first time a resident had absconded from the facility in that same way.

The care Nathan received from Hollins Park and the safety of the garden area, along with the incorrect information provided to Cheshire Police were reviewed throughout the inquest.

Concluding the inquest, area coroner Victoria Davis confirmed the medical cause of Nathan’s death to be 1a multiple injuries followed by 1b impact of a running train.

She said: “From the evidence we have heard, we believe Nathan Lee Cunliffe received an appropriate level of care and attention whilst on Austen Ward at Hollins Park Hospital.

“In regards to the circumstances of Nathan absconding from Hollins Park on January 11, 2022, we find based on the evidence that there was an insufficient risk assessment of the garden area and environment and an inappropriate staff to patient ratio whilst on garden leave.

“We do not consider the above to be direct contributing factors to Nathan’s death which we conclude from the evidence is to be suicide.”

Ayse Ince, the specialist medical negligence lawyer at Irwin Mitchell representing Lauren during the inquest, said following the hearing: “The inquest has provided Lauren with an opportunity to understand what happened to Nathan and ask questions around the care he received.

“Sadly, the Hospital Trust’s own internal investigation report identified worrying issues in the care Nathan received. We therefore welcome the changes now implemented by the Trust to improve patient safety.

“People affected by mental health are some of the most vulnerable in society and should be cared for by the appropriate services at the highest standards.”

Summarising the outcome of the inquest, Lauren added: “It’s almost impossible to describe how I felt when I was told Nathan had died. There’s not a day goes by when I don’t think about him and how he died.

“I would do anything to have him back, but I know that’s not possible. Reliving everything again at the inquest has also been difficult, but at least I finally have some answers.

“All I can hope for now is that more is done to improve mental health services so other families don’t have to go through what we have.”

Samaritans is available round the clock, every single day of the year, providing a safe place to talk for anyone who is struggling to cope.

Call 116 123 (this number is free to call and will not appear on your phone bill), 01204 521200 or email jo@samaritans.org.