University of Hertfordshire student dies after mental health services mix-up, inquest hears

PUBLISHED: 13:34 28 June 2018

The Old Courthouse in Hatfield, where the inquest was held. Picture: JP Asher

The Old Courthouse in Hatfield, where the inquest was held. Picture: JP Asher


A University of Hertfordshire student took his own life after a psychologist's recommendation for contact with mental health services was not followed up, an inquest heard.

Joseph Neal, 37 at the time, was found in the early hours of January 12 hanging at Trident Place car park near Mosquito Way.

Hatfield’s Old Courthouse heard how Mr Neal had suffered long-term mental health problems and had previously attempted to take his own life.

He had been seeing a psychologist back home near Warwick, and after moving to Hatfield 2017, a letter was sent to Potterells Medical Centre detailing his situation.

Senior Coroner Geoffrey Sullivan said: “Joseph moved to Hertfordshire and was given a letter from the psychologist, which provides background about depression and difficulties in his childhood, and there is a recommendation that he engage with local psychological services.

“This letter was clearly placed on Joseph’s medical record – it’s there in the printout provided by the surgery.

“He was seen on October 16 and he ought to have been referred to the local mental health services then, but he wasn’t.”

After a separate suicide attempt around the Christmas period, Mr Neal got in touch with doctors and subsequently mental health services, which led to follow-up meetings being arranged.

But police were alerted during the early hours of January 12 that Mr Neal had sent a text stating his intention to take his own life.

He was eventually found by officers who attempted CPR, but was pronounced dead at 3.22am.

Coroner Sullivan said: “I have to consider whether or not matters, certainly involving care, either causes or contributes to the death.

“And whilst it’s right he wasn’t referred at the time, he was seen by the mental health team, albeit shortly before his death.

“But to my mind it would be speculation really [to say whether] had this matter been raised by either the doctor or by Joseph himself, whether or not this outcome would have been different.”

He added that the most important thing was that the handover process was reviewed to avoid a repeat, and said a reflective session had been arranged for all the professionals involved.

The death was officially listed as suicide.

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