The inquest into Dan’s death was always going to be extremely difficult for those who knew and cared for him to listen to, report on and read about. But it is vital that lessons are learned from the mistakes that have been made so that others do not suffer or slip through the net the way he did.

It was deeply frustrating for Dan’s family and friends to hear in court how poor communication and record-keeping by members of Merseycare’s crisis response team, as well as a lack of professional curiosity, meant no one explored why Dan , who made two serious attempts. about his life a few days earlier, could cancel a scheduled appointment the day he died.

Team members admitted they had made “huge mistakes” in communicating and recording Dan’s care plans and appointments, while it was revealed that only one mental health practitioner made the decision to reduce his home visits Dan, with no record of this significant change and no discussion with other team members. Listening to this evidence, the mood of frustration and anguish among Dan’s family and friends in court was palpable. They could see the opportunities that were missed to protect him.

They also heard about the worrying shortage of staff, which meant that on the night Dan was assessed following a suicide attempt, there was only one mental health nurse in the whole of Royal Liverpool Hospital who could perform this function and could make a critical decision as to whether he should remain in the hospital. hospital or go home. He may have managed to contact a registrar, but there was only one person on duty covering the whole of Liverpool and down to Southport.

As the coroner made clear, no one working in Dan’s care would ever have wanted this outcome, and some of the witnesses who gave evidence were clearly distraught this week. But it is absolutely vital that these mistakes are addressed and learned from. Merseycare carried out an investigation after Dan died and told the court that improvements had been made to training, record keeping, senior staff and processes when patients cancel arranged visits.

After the coroner’s significant verdict that there was an arguable breach of the state’s duty to protect Dan’s life and wrongs that could contribute to his loss, Dan’s cousin Amos, who fought tirelessly and inspiringly for justice for Dan, talked about him outside the court. deep frustrations – as well as his relief at the verdict.

Mr Waldman said: “It was incredibly difficult, it hit me today, when the coroner made those findings. He said there were real possibilities. Anyone who heard what came out of the inquest will be thinking why did they do that? Why what did he not do in the first place, why, without any change in risk, did they alternate it with visits every other day. It was incredibly frustrating that these opportunities were missed?

“I heard from the witness who assessed him at the hospital that she was the only qualified person at that hospital that evening and when we spoke about what she would do to escalate the situation, she was able to speak to a specialist psychiatric registrar on duty who covers the whole of Liverpool up to Southport. She was essentially a psychiatric nurse placed as a clinical head and she had a huge responsibility and I have some sympathy for the lack of resources.

“But it is clear from the community team that they have not been properly qualified or resourced and there are major issues that need to be looked at. Dan should be here by now. Hopefully we can move forward and hopefully people will learn from this process.”

Mr Waldman added: “For someone who has spent his whole life campaigning for social justice, it is only right and proper that he get justice himself.”

Having achieved this justice and such an important inquest verdict, Dan’s family and friends will now continue to carry on his incredible legacy through the Dan Kay Foundation, which already raises huge sums of money for the causes he held dear – including mental health, spreading kindness and giving opportunities to the less fortunate.

One thing is certain, Dan Kay’s unwavering passion for supporting others and fighting injustice will live on in his name and he will always be remembered as a selfless, kind and caring man who did so much for so many.

A spokesman for Mersey Care NHS Foundation Trust said: “We are aware of the inquest into the death of one of our service users and would like to extend our deepest sympathies to the friends, family and loved ones of the deceased at this difficult time.

“Mersey Care prides itself on being a learning organization and regularly reflects on all our practices, but especially so after a tragic incident like this. Immediately following this incident, we conducted a serious incident investigation and updated our practices in line with the recommendations of our internal review.

“We will continue to monitor our standards of care throughout our services. As a Trust, we remain committed to providing high quality care for all our patients, service users, carers and their families.”