Jury finds missed chances contributed to footballer’s death

Colin Flatt, 81, died on September 7, 2021, after a series of moves between hospitals and care homes in the final months of his life.

A jury of 10 people reached their conclusions shortly after 5pm on Wednesday, after seven days of sitting at Seax House.

Speaking on behalf of the jury, the foreperson said: "Following a short stay at Broomfield Hospital on 25 May 2025, until he was admitted to Goodmayes Hospital where he was detained under Section 2 of the Mental Health Act 1983, Mr Flatt was then released on June 17.

"This led to an unsettled period of time between June 7 and July 2021 where Mr Flatt stayed in two care homes and his own home."

The jury noted that Mr Flatt had shown "increased confusion, agitation and aggression" during this period.

Deterioration - The inquest heard Mr Flatt was heavily medicated, which had a negative impact on him and contributed to his decline (Image: Melanie Leahy)

They identified several missed opportunities which contributed to his death, with his release after being detained under the Mental Health Act; the referral to RAID (rapid assessment interface and discharge team) not being done; the handover between Anisha Grange Care Home and Basildon Hospital not being done; and no handover between the wards at Basildon Hospital.

An absconsion risk assessment was also not completed.

Mr Flatt’s partner of 19 years, Melanie Leahy, spent five years seeking answers about his death.

On May 25, 2021, Ms Leahy used a home blood pressure monitor and recorded his heart rate as 35 beats per minute. The inquest heard Mr Flatt was admitted to three hospitals and two care homes between May 25 and September 6, 2021.

Sport - Mr Flatt was an ex-professional footballer who played for Southend United, Barnet, Leyton Orient and Romford in the 1960s and 1970s (Image: Melanie Leahy)

On July 21, Mr Flatt absconded from Anisha Grange care home and was taken to Basildon Hospital, where he stabbed himself in the abdomen with scissors before falling onto a glass table.

He was admitted to critical care on August 4 and later transferred to intensive care.

Mr Flatt was discharged home on September 6 and died the following day.

A post-mortem recorded his causes of death as bronchopneumonia, lung damage, and heart failure, alongside abdominal wall damage and behavioural disturbances requiring sedation.

The jury recorded the scissors wound, his fall, and an infection after surgery on July 28 as probable causes of death.

The inquest forms part of the Lampard Inquiry into mental health deaths in Essex.