Sad Man Looking Through Window

Inquest Finds Suicide Victim's Death was Contributed to by Neglect

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Claire Macmaster

Associate Solicitor, Public Law and Human Rights

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TW: This article covers themes of suicide.

According to the Office for National Statistics (ONS), the suicide rate in England and Wales was at 11 deaths per 100,000 people in 2021 and it is the biggest cause of death for men in the UK. These statistics equate to 18 suicides per day, meaning that the rise in suicide is a sad reality for those that struggle with mental health.

The devastated family of Terry Bennett, who committed suicide after repeated calls for help ‘fell on deaf ears’ have called for more to be done to prevent future tragedies. After an Inquest into his death, in 2018, it was found that the NHS Trust responsible for his care was at fault.

Terry Bennett was a 45-year-old man who had a long-standing history of serious and complex mental health problems, which required periods of hospitalisation. These mental health struggles also meant that he was unable to live independently.

But despite the extent of his needs being well known to Avon Wiltshire Mental Health Partnership NHS Trust, he took his own life at his family home in Warminster following a relapse. In the week leading to Terry’s death, two nurses were called to his home, and they concluded that he was not at an immediate risk of suicide. Sadly, Terry’s mother felt like she wasn’t given an easily accessible emergency contact number, and felt “abandoned” by the trust once the nurses had left her son in these call outs.

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After Terry’s Passing 

His family contacted INQUEST, a charity providing support and expertise on state related deaths and their investigation to bereaved people, and were represented by our Public Law Solicitors here at Simpson Millar. We, along with INQUEST had ‘grave concerns and doubts’ about the care Terry received in the months, and in particular the final hours, leading up to his tragic death.

Once the Inquest was concluded on the 14th September 2018, one of our solicitors said the family felt they ‘finally had the answers and the justice they had been fighting for’, after a Jury at Wiltshire Coroner’s Court, Salisbury, concluded that he died by suicide, but that his death was ‘contributed to by neglect’.

Tracee Cossey, Terry’s sister said, “My brother was a loving, creative, intelligent and warm-hearted man, who was also very ill and had been for many years. The family relied on professionals to support Terry and to keep him safe, yet he was allowed to drift and deteriorate without anyone being aware of how poorly he was or take steps to help him and stop him from harming himself”.

Following the conclusion of the Inquest, a Public Law Solicitor said, “The family have fought long and hard to expose the circumstances surrounding Terry’s death, and to understand whether more could, and should, have been done to help him in his final hours”.

“Throughout the Inquest the Jury heard evidence of a general, and yet very basic system failure to ensure adequate care for Terry resulting from a lack of staff expertise, supervision, team communication, record keeping and case review”.

“The consequences of such failings have been quite devastating, and the family are now calling on Avon Wiltshire Mental Health Partnership NHS Trust to ensure that immediate measures are put in place to prevent future tragedies, and that any such measures are communicated to the public to provide reassurances to those who rely on the service for their own wellbeing, and the wellbeing of their loved ones”.



Terry took his own life on the 27th of October 2016, where he cut his throat and wrists, and then threatened to harm his mother. Sadly, he died within an hour after his self-inflicted injuries.

He had battled mental health issues for much of his life, and was under the care of Avon Wiltshire Mental Health Partnership NHS Trust where he had previously been allocated a care coordinator from a Community Care Team whilst receiving support from a psychiatrist.

But despite his background, it is now understood that he was discharged from his Community Treatment Order with inadequate planning, and that once discharged he had received inadequate support – which resulted in this sad passing of a vulnerable adult.

A Solicitor from Simpson Millar said, “As part of the Inquest the Jury heard that Terry’s mental health began to deteriorate in September 2016, at which point he had not been seen by the support team for four months”.

“Despite his mother’s desperate efforts to prevent him from self-harming he took his own life on October 27th. She remains devastated that her repeated calls for help from the Community Care Team simply fell on deaf ears”.

“His family feel strongly that had he received the support he so greatly needed his tragic death could have been prevented, and are relieved that the Inquest has supported their concerns”.

Terry’s sister Tracee added, “Finally, the family have been given the opportunity to discover the true extent of the failings, received a sincere apology from the NHS Trust and had our doubts and concerns supported by the Jury and the Court”.

She went on to thank the Jury and Assistant Coroner Nicholas Rheinberg for their time and careful consideration throughout the Inquest which started on 3rd of September, 2018 and lasted two weeks.

Deborah Coles, Director of INQUEST said, “The failures highlighted by this Inquest show a familiar story of a family left to care for someone profoundly unwell, only helped when things meet crisis point. For Terry this was far too late. The deficiencies in the systems and practices of Wiltshire mental health services evidenced here, should be considered at a national level”.


Accessing Support

If you’re concerned about someone who you think could be vulnerable or you need some extra support yourself, the following charities offer help, advice, and online resources:

  • Samaritans – open 24 hours a day, 365 days a year 116123 (freephone)
  • MIND – Mental health charity
  • CALM (The Campaign Against Living Miserably) is known for supporting male mental health; but, they will support anybody who needs them. Their helpline is open 5pm- midnight, 365 days a year. 0800 58 58 58
  • Papyrus – Suicide Prevention Charity – open 9am – midnight every day of the year Call 0800 068 4141 or Text 07860 039967
  • Hub of Hope – a database of Mental Health Services thought the UK


Don’t struggle alone – reach out for help 

The International Association for Suicide Prevention (ISAP) say that the best thing we can do is take time to reach out to our loved ones. You may feel reluctant to talk to them about suicide in fear of saying the wrong thing but it’s important to remember that you don’t need to have all the answers.

If you’re experiencing suicidal thoughts or you’re worried about someone close to you, please reach out.

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Claire Macmaster

Associate Solicitor, Public Law and Human Rights

Areas of Expertise:
Public Law & Human Rights

Claire joined Simpson Millar in May 2019 and works in the Claims against Public Authorities Department in our Public Law Team in London.

She has a mixed practice of public law and civil damages cases, as well as representing bereaved families at inquests. Claire completed her training contract with Leigh Day, training in the Personal Injury and Human Rights Departments and qualifying into the latter in September 2018.

Her main interest is in obtaining remedies for women and young people who have survived sexual and gender-based violence and exploitation and who have been failed in this respect by public authorities.


Office for National Statistics (ONS). (2021). Suicides in the United Kingdom: 2021 Registrations. Retrieved from

BBC News. (n.d.). Wiltshire Mental Health Patient Deaths: Inquest Call. Retrieved from

Inquest. (n.d.). Inquest - The Only Charity Providing Specialist Support and Advice on State-Related Deaths and Their Investigation. Retrieved from

Avon and Wiltshire Mental Health Partnership NHS Trust (AWP). (n.d.). Avon and Wiltshire Mental Health Partnership NHS Trust. Retrieved from

International Association for Suicide Prevention (IASP). (n.d.). International Association for Suicide Prevention. Retrieved from

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