There were police and healthcare “shortcomings” before the suicide of a man in Middlesbrough, an inquest has heard.

In September 2020, Leon Abed Ali was 23 when he died at LA Motors Innes Street in Middlesbrough, following a turbulent period for his mental health.

In the days preceding his death, Leon had multiple interactions with both Cleveland Police and Tees, Esk and Wear Valley NHS Foundation Trust (TEWV) – but the alarm about Leon’s suicidal ideation was not raised.

Despite identifying “shortcomings” in how police dealt with these preceding incidents, the coroner did not make the causal link between these and Leon’s death.

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Between September 26 and September 29, 2020, Leon interacted with police on three occasions, and staff from TEWV twice.

On September 26, police were called to an incident where Leon had taken an overdose in his vehicle outside Sporting Lodge Hotel.

Whilst Leon was in custody, Leon’s mother Susan Hughes had telephoned the station expressing concern for Leon’s mental state and outlining that he needed support. Leon was assessed by a registered mental health nurse at TEWV at the station, before being released.  

The following day, only an hour and a half after his release from custody, police became aware that Leon was once again in an “immediate threat to life situation” after he spoke to an ex-partner and threatened to kill himself.

After a search, officers found Leon on Victoria Bridge in Stockton. He threatened to jump over the side of the bridge if approached by officers, but eventually got back into his vehicle and was joined by a friend, Stephen King.

At the scene, Leon's sister was prevented from talking to him. Statements from police outline that this was because Leon's reported view was that he did not want her there. 

Leon was left in Mr King’s care by the police, despite Mr King telling officers that he was not comfortable being responsible for Leon.

The coroner outlined that there was “no clear picture of exactly who was managing the incident at the scene”, and “no clear picture of who at the bridge knew about incidents from the previous night”.

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They also concluded that the decision not to section Leon was “not necessarily wrong”, safeguarding concerns should have been raised and documented, but “nothing seems to have happened”.

The coroner deemed that the incident “was not dealt with as it should have been”, with “different officers knowing different things”.

The day before his death, Leon was seen by Jennie Thompson, an experienced mental health professional - but Ms Thompson did not have a complete account of recent incidents.

Though she accessed Paris, a patient record software used by healthcare and police, and knew of his low mood, thoughts of self-harm, and substance use, there were gaps in the records.

Ms Thompson was not aware of Leon’s expressions of not wanting to be here, attempts to tie ligatures around his neck, family concerns, or any of the details of the bridge incident on September 27.

However, when giving evidence to the inquest, Ms Thompson was “very clear that the missing information would not have altered the outcome of her assessment”. Leon was referred to his GP for medication to help deal with his depression.

The coroner concluded that “notwithstanding the findings and concerns I have raised, I cannot make the causal link between these shortcomings and the outcome for Leon.”

Nadia Abed-Ali, Leon’s older sister, told The Northern Echo that Leon’s death had left the family “devastated”.

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“It has been truly awful coming to terms with it. With this inquest, we have some closure, but we are still grieving. He has left a massive hole in our lives and in our hearts.”

Paying tribute to her brother, Nadia said: “He would’ve done anything for anyone – he just needed help, and he’s not here because he didn’t get the right help. That’s the long and short of it.

“What I don’t understand is why he was treated like a criminal – the way he was spoken to by police, the doctors refusing to see him because he was agitated. People with mental health issues shouldn’t be treated like that.”