A coroner has delivered a damning condemnation of the mental health treatment of a psychotic man in the months before he threw his 11-month-old son into a river and to his death.
The failures leading up to the horrific events which claimed the life of Zakari William Bennett-Eko on September 11, 2019, represented an 'arguable breach' of Article 2 of the Human Rights Act , which says government organisations have a fundamental legal duty to protect life, the Rochdale inquest was told.
Senior coroner for Manchester North, Joanne Kearsley, said there were 'many failings and missed opportunities' in the care of dad, Zak Bennett-Eko, who was later convicted for his son's death of manslaughter by diminished responsibility and sentenced to a hospital order. He may never be released.
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Ms Kearsley was bringing to a close a three-week long inquest into the death of baby Zakari, who died as a result of immersion in cold water after being thrown into the River Irwell at Radcliffe, just yards from where they lived.
She said: "As important as they [the failings] are, many cannot be said to have had any direct causal link to September 11. In fact, it must be remembered that, in terms of causing Zakari's death, there is ultimately one person who caused his death."
But she went on: "There is one factor which I find can be said to have contributed to the death, in that I am satisfied on the balance of probabilities there was a missed opportunity to ensure Zak had appropriate ongoing secondary [hospital] mental health input from January 2018 until September, 2019."
Referring to the treatment of the dad, who suffered from paranoid schizophrenia, ADHD and had mild learning difficulties, Ms Kearsley pointed to 'the failure to have in place an integrated community learning disability service which provided psychiatric and mental health support and co-ordination'.
"On balance I find this was a missed opportunity which could have assisted in the prevention of a relapse, as there should have been an earlier intervention when he was not prescribed with his medication and when he was seeking help in May 2019 and later on.
"In addition, other professionals including GPs, social workers, the mental health liaison team [at North Manchester General Hospital ] and family members would have had contact with a service who knew him and when he was asking for help.
"The missed opportunity to prevent this relapse in my opinion possibly contributed to his actions on September 11."
Delivering an 'unlawful killing' conclusion, Ms Kearsley said there was an 'inadequate' community learning disability service in place in Manchester. She said a care programme approach had been discontinued 'when it should not have been and Zak did not have a worker in a care co-ordinator role which he should have had'.
She continued: "Between May and September 2019, necessary medication was not prescribed to the individual and it is more likely than not his mental health deteriorated during this time.
"On six occasions between August 31 and September 11, 2019, he sought help for his mental health and presented at his GP, A&E and the mental health liaison team.
"Had appropriate monitoring of the individual's mental health care been in place, his presentation and medication could have been monitored and there would have been a care co-ordinator for other professionals and family members to liaise with.
"On the balance of probabilities, his non-compliance with necessary medication would have been identified at an earlier stage and it is possible that this could have averted the acute deterioration in his mental state.
"There is no evidence to suggest Zakari would have died if it had not been for the individual suffering a psychotic episode."
Turning to Zak's mum, Emma Blood, who since the tragedy has had a baby daughter, Ms Kearsley said: "I am sure I am not alone when I say I don't think anyone can imagine the horror that you have had to endure and face.
"I hope this [inquest] helps your understanding as to why the events of September 11, 2019, happened. I know you have a daughter now and I hope that in the years to come you will remember Zakari with the love you clearly showed.
"There were many positive words spoken about Zakari and the family you have. The death of Zakari was horrific and I'm sure you have the deepest condolences of everyone who has been in court these last three weeks."
Commenting on the coroner's conclusion, Emma, said: “There should have been more monitoring in place and a care coordinator in place which I believe would have helped avoid the deterioration in Zak’s mental health that led to the death of my son.“
Kelly Darlington, solicitor for Emma, said “This is an extremely distressing case that no mother should ever have to experience.
"The inquest into the death of Baby Zakari highlighted a number of multi-agency failings in the care of his father who was experiencing a serious relapse of his psychosis at the time of the horrific events that led to his death.
"These missed opportunities may have avoided the serious deterioration in the father’s mental health that led to the unlawful killing of Baby Zakari.”
Eight organisations and baby Zak's mum were legally represented at the inquest. The organisations were: Greater Manchester Mental Health Trust, Manchester City Council, Bury Borough Council, Manchester Clinical Commissioning Group, Manchester Foundation NHS Trust, Pennine Care NHS Foundation Trust, Mersey Care NHS Foundation Trust, Rock Health Centre and Greater Manchester Police.
Ms Kearsley has given legal representatives of all eight organisations 28 days to prepare submissions in advance of a 'Regulation 28 Prevention of Future Deaths' report.
The report will be sent to authorities which have the power to make the changes that are suggested. Organisations have to respond to these within 56 days showing how they have made changes according to the coroner’s recommendations, or how they intend to. All Prevention of Future Death reports and responses are sent to the Chief Coroner.
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