A MAN with a history of mental health issues killed himself just one week after being arrested for an alleged domestic incident, an inquest has heard.
Aaron Anthony Sanson, of Hamilton Road, Bournemouth, was found hanged from a tree near Tuckton Tea Rooms, Christchurch, last September.
During an inquest into the 24-year-old's death, held at Dorset Coroner's Court, Bournemouth, on Tuesday, Mr Sanson was described as an "intelligent and articulate" young man.
The father-of-two was arrested on September 14, 2018, following the alleged incident.
But he fled from police, self-harmed with a broken bottle and ran along a railway track before being apprehended.
Then, at Royal Bournemouth Hospital later that day, while he was still under arrest and accompanied by police officers, he was seen by a mental health nurse with the hospital's psychiatric liaison team.
However, due to the circumstances of his arrest, the inquest heard, this nurse was unable to carry out a complete risk assessment and treatment plan.
This should have been carried out later at Bournemouth Police Station, but it did not take place.
Assistant Dorset Coroner Brendan Allen said: "Mr Sanson should have been seen at Bournemouth custody, but he was not.
"I cannot know whether the outcome of that assessment, that did not happen, would have resulted in a referral to services.
"It was a missed opportunity to re-engage with Mr Sanson, and to find out what he wanted."
Mr Allen said it remained unknown whether or not any referral would have changed the eventual outcome. But he stressed: "That does not detract from the fact that that assessment should have happened."
A subsequent healthcare review into the case has already resulted in new procedures being introduced to ensure communication between hospital and police station mental health liaison teams is formalised, the hearing heard.
Now in similar circumstances when someone has been seen at the hospital, said Mr Allen, there must be a phone call between the psychiatric liaison teams at the hospital and the police station to find out what assessment has been conducted and how far that assessment has gone.
The assistant coroner said this was "to ensure a situation like this does not arise again where someone slips through the net."
Mr Sanson had been under the care of community mental health services for a number of years, but had last engaged with them in July 2017, the inquest heard.
After being released by police he stayed at his partner's address, with her permission, despite police bail conditions to the contrary.
On September 21, 2018, he was due to stay at a friend's house, and contacted his partner where an angry exchange took place.
Mr Allen said: "The last conversation they had was calm.
"There was no cause for concern that he would harm himself at that time
"It seems to me it would have been impossible to predict he would go on to do what he did."
Mr Sanson was found at 7am Tuckton Tea Gardens, Wick Lane, Christchurch, the following day.
He had hanged himself and taken an overdose of medication.
Mr Allen recorded a conclusion of suicide.
If you're struggling with your mental health the Samaritans helpline is available 24 hours a day on 116 123.
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