Jamie was a 31-year-old man who tragically took his own life on 4 June 2022.
Following hearing 4 days of evidence at Chelmsford Coroners Court, HM Area Coroner Sean Horstead found multiple failings in the care provided to Jamie, which contributed to his death.
Whilst Jamie was not detained by the state, HM Coroner found article 2 to be engaged on the basis of the operational duty. As HM Coroner found the operational duty to be engaged, he did not go on to consider the systemic duty.
Jamie had a long history of mental health difficulties, including psychotic-like symptoms, hearing voices and paranoia linked to the use of illicit substances at a young age. In 2017, 2018 and 2019, Jamie engaged with mental health services, and it was recorded that his symptoms were improving. Following a change of care coordinator Jamie’s engagement with the service reduced and ultimately, he was discharged at the end of 2020.
Jamie was re-referred to the mental health services in November 2021, initially by contact from his mother, then two urgent GP referrals. Jamie was assessed by the First Response Team in January 2022, and a plan was made for Jamie to have a medication review and be discussed in an MDT meeting. A further urgent GP referral was sent in May 2022. HM Coroner found that Jamie never received a medication review and was never discussed in an MDT meeting.
On 3 June 2022, Jamie was taken to Basildon Hospital by ambulance due to a deterioration in his mental health, including having not slept for 3 days, and thinking people were going to hurt him. Jamie was assessed in A&E and the note of this assessment includes “worsening symptoms, very low mood 0/10, feels suicidal… impression: depression with suicidal ideation”. Jamie was referred to the Mental Health Liaison Team where an assessment was undertaken. As a result of this assessment, the assessing practitioner told the Court that he felt Jamie would benefit from voluntary inpatient admission, but ultimately Jamie was discharged home with a plan for the Home Treatment Team to review him in the morning.
Jamie tragically took his life that night.
HM Coroner found that the following failures contributed to Jamie’s death and cumulatively amounted to neglect:
HM Coroner also found that the assessment undertaken by the Mental Health Liaison Team Practitioner on 3 June 2022 was inadequate and failed to recognise or appropriately act upon relevant information available to him. HM Coroner concluded that the failure to initiate the process for admission to an inpatient bed was a ‘clear missed opportunity to ensure appropriate, and likely effective, steps were taken following the assessment to mitigate [Jamie’s] high risk of acting upon his suicidal ideation”.
HM Coroner expressed that whilst he heard evidence on learning and changes that have taken place since Jamie’s tragic death, he continued to have concerns about some practices at the trust, including training on supporting those with a dual (mental health and substance use) diagnosis and will be writing a Prevention of Future Deaths Report to the Trust.
Emily Slocombe was instructed by Lily Hedgman of Leigh Day.
