A man who was arrested for his father's manslaughter, then dearrested and rearrested on a different charge, may still have been alive if medical notes used by the police were not "inadequate", a coroner has said. 

John Hurst, 49, from Sunderland, was the main carer for his elderly father at the time of his dad's death in September 2021. 

The police arrested John on suspicion of involuntary manslaughter, because of "the length of time before John had sought assistance from emergency services, his demeanour upon police arrival and notes containing disturbing content within the premises".

Quickly, John was dearrested but rearrested on suspicion of possession of a controlled substance. 

Despite warnings from his sister and officers involved in the investigation, an assessment by Cumbria, Northumberland, Tyne and Wear NHS Trust (CNTW) found that he was fit to be released from a police cell. 

John was released from custody on the afternoon of September 13, 2021. He was last heard from later that evening. 

Only two days later, John was found by a passer-by near to train tracks. John died due to the effects of a haemorrhage. 

Now, the assistant coroner for Sunderland David Place told both Northumbria Police and CNTW they should take action to prevent future deaths.

Both organisations told the Northern Echo they are working on improvements. 

John had a diagnosis of paranoid schizophrenia, a mental health condition that affected how he thought and behaved, and had tried to take his own life three times in the past. 

However, following an assessment by the CNTW staff at the Criminal Justice Liaison and Diversion Service (CJLD), John was deemed fit for both interview and release from custody. 

At an inquest into John's death, the coroner heard that the custody sergeant who decided to release John was "greatly assisted" by the CJLD's information when completing a release risk assessment.

The court heard that "the electronic custody record contained limited information about the concerns of police officers and John’s sister, and there was a distinct lack of detail about the assessment itself and very little analysis of the concerns and reasoning for the CJLD conclusion."

In a prevention of future deaths report, the coroner wrote that he was concerned that "the electronic custody record was inadequate and  lacked detail regarding the concerns for the detained person’s mental health."

Missing and inadequate detail on worries from police officers and family, the risk of suicide, the content of notes found and mental health history could lead to "future deaths" if action is not taken by organisations. 

The coroner added: "I am concerned that the record also lacked a detailed analysis of those concerns by CJLD and comprehensive reasoning for the assessment conclusion. 

"Deaths may be prevented if the recording of information in such cases is reviewed."

A Northumbria Police spokesperson said: “Our thoughts remain firmly with the family of John Hurst following his death in September 2021.

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“We are carefully considering the report from His Majesty’s Assistant Coroner and will reply in accordance with our statutory obligations.”

CNTW added: “Our thoughts are with Mr Hurst’s family and friends at this difficult time.

"We take all concerns seriously. We are reviewing our processes with our colleagues at Northumbria Police to address the concerns highlighted by the coroner. We will respond to the coroner within the timescales provided.”

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