Inquest into the death of Christopher Sidle

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The inquest into the death of 51-year-old Christopher Sidle, from North Walsham, concluded today, 22 March 2024, in Norwich in front of Norfolk’s Senior Coroner, Jacqueline Lake. Ashtons Legal are representing the family.

Mr Sidle died on 4 July 2023 as a result of injuries sustained when throwing himself from a moving car three days earlier. At the time of the incident, he had been suffering from a period of psychosis for over three months.

Christopher Sidle - 2009

Pictured: Christopher Sidle in 2009.

Mr Sidle had worked for the government as a climate change officer before experiencing his first episode of psychosis in December 2011. He was diagnosed with paranoid schizophrenia but, with medication, recovered fully and was discharged from mental health services. He experienced a second episode of psychosis in 2014, when a further diagnosis of acute psychosis and paranoid schizophrenia was made. Following the introduction of medication and an in-patient stay, he again recovered well and was discharged home.

He remained well and stable on a low dose of medication for almost ten years with no ongoing mental health care. He had a brief relapse in 2021, for which he presented at his out-of-hours GP service, but early intervention enabled him to be completely well four days later.

Mr Sidle then suffered a relapse in March 2023, the cause of which remains unclear.

On 28 June, Mr Sidle telephoned his sister during the night, acutely psychotic, stating that he had “three days left to live”. The Community and Crisis Teams were made aware of this, but no action was taken. The countdown continued the next day, and Christopher’s sister repeatedly contacted the Community and Crisis Teams with her concerns. The day that Christopher threw himself out of a moving vehicle was “day zero”.

Pictured: Christopher Sidle in 2017.

Pictured: Christopher Sidle in 2017.

An internal investigation conducted by the Norfolk and Suffolk Foundation Trust has concluded that there were multiple missed opportunities in Christopher’s contact with their services and that these were contributory factors to the incident that occurred on 1 July 2023.

Tom West, Solicitor at Ashtons Legal, provides the following statement on behalf of the family.

“Chris was a wonderful, intelligent and kind man who spent his life helping to improve the lives of others. He leaves behind a devastated family and missed friendship.

We would like to thank the Coroner for her thorough and thoughtful investigation, and we welcome her findings today that there were missed opportunities to provide appropriate and timely care to Chris and that the assessments carried out in respect of his mental health were inadequate.

We are also grateful to those who have given evidence this week. As a family, we do not hold the individual clinicians involved in Chris’ care personally accountable for his death – from our perspective, they, too, are victims of a failing and dangerous system. We know that Chris would echo this opinion.

We remain of the view that Chris’ death was entirely avoidable. We expect the Trust to take the Coroner’s findings seriously. It must follow through with its action plan to address the failings that have been identified. Until this Trust‘s systemic, long-standing failures are remedied – which it has failed to do despite having been in and out of special measures for nearly a decade – there will be further avoidable deaths and families left wondering why previous warnings were not heeded.

We are aware that there have been calls for a public inquiry into the quality and delivery of mental health services carried out by NSFT, and we as a family support those calls.”


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