T/W: References to suicide
An inquest into the death of Michael William Goodchild, 22, was told he had “slipped through the net”.
He was known to mental health staff and charity workers, South London Coroner’s Court heard – but his family believed opportunities to save his life were missed.
“Michael never spoke to the same person twice,” said their barrister Patrick McMorrow.
“So many people were involved. He went to so many triages and never got through. It is hard to pinpoint where something went wrong.”
The inquest got underway two-and-a-half years after he died, after two postponements and delays due to missing evidence.
Mr McMorrow said he still “felt that there were a number of documents missing from the bundle that may have assisted the court” and that the investigation was “limited in areas.”
“This is a case where it would appear from the documents that Michael attempted to get help from various organisations from October 2020 to the time of his death,” he told coroner Ivor Collett.
“In September 2021, he was admitted to Lewisham hospital after an attempt to take his own life.
“It was recommended that he needed a mental health recommendation at that time but he was discharged without.
“He just seemed to keep slipping through the net.”
The court heard there had never been a face-to-face meeting after Michael attempted to take his life in 2021, when there was a possibility he could have been sectioned.
Mr McMorrow said a nurse had noted symptoms of psychosis in December 2021 and referred Michael to the intensive case psychosis team.
The referral was refused in March 2022 on the basis there was “no evidence of psychosis” and no assessment was carried out.
The barrister questioned why the referral was declined given the nurse’s observations, adding that Michael was also under gastroenterology care due to damage to his body.
In October 2022, further concerns were raised by homelessness charity St Mungo’s, flagging that he was suffering from depression and low mood.
Other concerns raised included two cancelled GP appointments in December 2022 at Belvedere Medical Centre, despite his history of poor mental health and struggles with drug addiction.
The coroner said further documents will be sought from Oxleas Bexley Hub, Pier Road Project, and Belvedere Medical Centre before the case can proceed.
These institutions are now interested parties in the case and will be entitled to send lawyers and make representations when it resumes.
The hearing has now been adjourned to an unknown date.
Michael’s mother, Mary O’Sullivan, has previously raised concerns about how evidence was handled by police after her son’s death.
She told the News Shopper two mobile phones were seized in February 2023 to be downloaded for the coroner, but only one was returned to her in March this year.
In an email exchange in May, Mary asked police why she had not been consulted before the phone was destroyed, stressing its irreplaceable personal content.
The Metropolitan Police told her that one device had been downloaded successfully, but the second, an older phone, could not be downloaded and was therefore disposed of.
Mary had not approved the destruction of the phone, and it remains unclear whether any information from it was ever passed to the coroner.
She said: “That phone had everything. Now it’s like they’ve erased him. I’ve never been given anything in writing – no proper explanation, no apology, nothing.”
Mary described the return of the single phone as lacking privacy and sensitivity, and said she refused an offer to complete a compensation form, telling officers she wanted accountability, not money.
Michael was known for his kindness and creativity, and had written and recorded a song about mental health before his death. He also enjoyed DJing with his brother and friends.
A Metropolitan Police spokesperson said: “Our thoughts remain with Michael’s family and friends.
“We understand they are rightly upset and frustrated about the service they received from us at an incredibly distressing time and have apologised directly to them.
“We will fully support the inquest to understand more and learn any lessons.”
