Andrew Connolly: Prevention of Future Deaths Report

Greater Manchester Integrated Care

I am, Alison Mutch, Senior Coroner, for the coroner area of South Manchester

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners  (Investigations) Regulations 2013 

On 20^th December 2024 I commenced an investigation into the death of  Andrew James CONNOLLY .The investigation concluded on the 30^th April 2025 and the conclusion was one of suicide. The medical cause of  death was multiple injuries. 

On 26th November 2024 Andrew James Connolly was struck by a train having entered the track at        [REDACTED] Railway Station and died there from his injuries.   

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur  unless action is taken. In the circumstances it is my statutory duty to  report to you. 

The MATTERS OF CONCERN are as follows.  –  

The inquest heard evidence that whilst initial appointments with his GP  were face to face they became telephone appointments even when he  indicated that his mental health was not improving. In addition there was no attempt to gain input from his family into the reality of the situation in  relation to his mental health. The evidence given by his family at the  inquest was that they could have provided valuable information into the clinical assessment but did not feel they had the opportunity to provide  this information.  

The consequence of these two factors was that his risk was not  recognised. 

On the evidence before the inquest there is no guidance for the use of  telephone appointments in preference to face to face for GPs across GM and no mechanism for family input in these situations. 

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.  

You are under a duty to respond to this report within 56 days of the date  of this report, namely by 5^th August 2025. I, the coroner, may extend the period. 

Your response must contain details of action taken or proposed to be  taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely : the wife of Mr Conolly on behalf of the  family, who may find it useful or of interest. 

I am also under a duty to send the Chief Coroner a copy of your response.  

The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make 
representations to me, the coroner, at the time of your response, about  the release or the publication of your response by the Chief Coroner.