The court heard that Darian’s discharge “should have been managed in a more professional way”
An Essex man was hit and killed by a train at an Essex station just months after being discharged from Essex mental health services. Darian Bankwala was killed after being hit by a train at Wickford Railway Station at around 4.40pm on December 27, 2020.
The 22-year-old was only discharged from the mental health services at Rochford Hospital four months prior to his death. An eight-day inquest hearing into Darian’s death, which began on March 23 at Essex Coroner’s Court in Chelmsford, has now concluded.
The court heard that Darian was the youngest of five brothers, and he was born and raised in Chelmsford,Essex. He had learning difficulties and some autistic traits which were never properly investigated or diagnosed, the court was told.
Darian coped “reasonably well” at primary school but began to struggle at the start of secondary school and his mental health began to deteriorate. After Darian left school at 16, his mental health stabilised and he was able to attend and enjoy college.
As Darian approached the end of his time at college, his mental health declined again. Although he successfully obtained a job at Domino’s pizza, he struggled to cope and unfortunately had to leave.
The much-loved son and brother’s mental health continued to get progressively worse until in February 2020, Darian’s parents were able to convince him to see a mental health nurse at Chelmsford Hospital. Despite his parents raising concerns and Darian showing warning signs of suicidal behaviour, he was not admitted for treatment, the court heard.
Instead, he was advised by a senior medical practitioner to self-treat at home, with “little to no professional guidance” as to what this treatment would involve. A few days later, after Darian was taken to A&E, he was admitted to Southern Hill Hospital in Norfolk, under section 136 of the Mental Health Act 1983.
Shortly afterwards, he was relocated to the Linden Centre at Broomfield Hospital in Chelmsford, which is run by the mental health service, Essex Partnership University Trust (EPUT). At the Linden Centre, Darian’s mental state further deteriorated. Despite this, he was given one hour of unescorted leave per day yet he frequently stayed on leave for longer and absconded several times.
In April 2020, Darian was transferred to Rochford Hospital under section 17 of the Mental Health Act 1983 where he continued to receive unescorted leave, subject to a medical professional’s approval. Darian’s condition continued to deteriorate, but the 22-year-old was discharged on July 7, 2020, without any discussion with his family.
Darian was provided with a care coordinator but his mental health deteriorated further whilst in the community. The family made his care coordinator and the Essex Partnership University Trust repeatedly aware of the situation but the support provided to them was limited.
On December 27, 2020, four months after his discharge from Rochford Hospital, Darian got dressed and left his family home at midday. Tragically, Darian was hit by a train at Wickford Station, close to his home, at 4.42 pm.
At the inquest, area coroner for Essex, Sean Horstead, expressed concerns about a number of points in his factual findings. He found that mild learning disabilities and autism were inappropriately excluded from Darian’s differential diagnoses during treatment and he express concerns that “someone with such vulnerability could be discharged to a destination unknown with the presumption that his family would take him back in”.
Coroner Horstead added that there was “disproportionate, unnecessary, and helpful fixation from clinicians and ward staff” on unsubstantiated substance abuse/drug-induced psychosis, ultimately leading to a final diagnosis of “mental and behavioural disorder due to multiple substance misuse”, which “[did] not accurately reflect the uncertainty or breadth of differential diagnoses that had been identified under section”.
It was also found that some of the comments made about Darian at a multi-disciplinary meeting level were “so out of keeping with any of the evidence…seen and heard that [they indicated]…a degree of malice on the part of those in the discussion” and suggested that the ward was “united in finding Darian to be something of an irritant”.
Finally, the coroner expressed that “discharge should have been managed in a more professional and thorough way with clear lines of communication and much clearer lines of involvement. [The professionals] should at least have given opportunity for consideration of deferred discharge [of Darian] as a voluntary in-patient”.
In a narrative conclusion, coroner Horstead stated Darian’s “discharge should have been managed in a more professional and thorough way” by EPUT staff.
Darian’s death ‘destroyed the family’
Darian’s father, Kobad, said that his son’s death will ‘remain with them for the rest of their lives’, and that his death had ‘destroyed’ their family unit. Kobad stated in evidence: “I had predicted that something like Darian’s death would happen, and I fought bitterly to prevent what ultimately did happen.
“It was a nightmare to get him into the system, it was a nightmare when he was in the system, it was a nightmare to stop him being released from the system and it was a nightmare after he was released. We now have another form of nightmare which will remain with us for the rest of our lives.
“We were a strongly knit family, always unified. Sadly, Darian’s death has destroyed the fabric of my family. It has changed all of our lives forever. Christmas and New Year will never be the same for us again. Darian has been stolen from us, from me and it need not have happened. As one of the nurses who looked after Darian at Southern Hill Hospital said to me, ‘what a waste of a young life’.”
Credit Essex Live