'No failures' in care of dad who fell to death

Warning: This article contains references to suicide

There were "no failures" in the mental health care of a father-of-two before he took his own life, an inquest has found.

Theo Schooling, 40, was granted unescorted grounds leave from the Priory Hospital Bristol on 16 January 2025, and was later found dead on the M32 motorway.

A jury at Avon Coroner's Court concluded Theo, who was described by his family as "intelligent and extremely kind", took his own life.

The coroner ruled on Monday there was "no evidence that there were any failures in Theo's care at the Priory that could have contributed to his death". The Priory Group has been approached for comment.

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Following the jury's conclusion, area coroner Dr Peter Harrowing said he would not be issuing a prevention of future deaths report.

"Having heard all the evidence, I am satisfied the Priory and the wider group have identified points of learning and steps have been taken to implement them," he said.

Theo, who had bipolar disorder, was described by his family as "bright, intelligent, charming and extremely kind".

After his mental health deteriorated following a hernia injury, Theo was detained under the Mental Health Act in Woolwich in London on 16 November 2024, before being sent to the Priory Hospital Bristol a week later.

Following an improvement in his mental health, he was "stepped down" on 16 December from the psychiatric intensive care unit (PICU) to Walter Ward, where his improvement continued.

The inquest was told Theo consistently denied having suicidal thoughts during his time at the Priory, except on one occasion.

Consultant psychiatrist Dr Prabhakaran Naveen told the inquest Theo told her he had "too much to live for" when asked if he had plans to hurt himself.

Theo was granted leave on more than 110 occasions, including more than 40 periods of unescorted grounds leave, with no previous concerns about him using this leave inappropriately.

Before his death, Theo had expressed frustration and anxiety at the lack of a plan to move him closer to home.

The jury was told it was not until late December – a month after Theo was moved to the Priory – that his correct NHS Trust in London was identified as part of a process to find a bed closer to home.

The nurses who granted Theo his unescorted grounds leave on 16 January told the inquest they had no concerns about his mental state.

This was despite his mother phoning that afternoon to say she did not believe her son was "back to his baseline" following a trip out into Bristol where Theo's behaviour was a cause for concern.

At about 17:30 GMT, nurse Kristen Tomlinson decided to grant Theo an hour of unescorted grounds leave. Dr Naveen had said any leave should "preferably" take place during daylight hours, but nurses could use their discretion.

In the jury's conclusion, they noted Theo was granted leave "beyond the prescribed 30 mins".

After leaving the Priory hospital's grounds, he was pronounced dead later that day. There were no witnesses to report what happened.

The inquest was told he died of a head injury and a toxicology report found no alcohol or drugs in his blood other than what he had been prescribed.

A spokesperson for Priory said Theo's death was a tragic incident which had a profound impact on everyone involved with his care.

"He had been improving and had completed more than 110 periods of agreed leave without incident during his admission, so his death came as a shock to the hospital team.

"Our thoughts and sympathies remain with Theo's family." they added.

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