Jonathan Baker, of West Bridgford, Nottingham, known to his family and friends as Johnny, was a beautiful soul. He was outstandingly handsome, cheeky, hilariously funny and had a brilliant, intelligent, inquisitive and complex mind.
Johnny was 24 years of age when he took his own life by running in front of a bus on 17th January 2024. This tragedy befell him just weeks after his discharge from Sherwood Oaks Hospital where he had undergone treatment for his mental health, and the day after a review meeting with the clinical team from the Nottinghamshire Healthcare NHS Foundation Trust who were meant to take care of him.
Johnny’s Inquest was heard in the Nottingham Coroner’s Court over 4 days last week, starting on Tuesday 21st May 2024. HM Assistant Coroner Michael Wall directed that Article 2 of the European Convention on Human Rights was engaged for the Inquest on the ground that Nottinghamshire Healthcare NHS Foundation Trust had arguably breached one or more of its substantive duties to preserve Johnny’s life, reflecting the public interest which arose in the determination of the inquest and in investigating the standard of care that Johnny received.
As the Coroner concluded, and as was painfully clear to Johnny’s family, there were a host of missed opportunities and failures by the healthcare professionals charged with Johnny’s care, of which the most significant was their failure to consider recalling Johnny to hospital when it was obvious that his mental state was deteriorating and that there was a real risk of him taking his own life. Johnny’s Community Care Co-ordinator, and his Responsible Clinician, failed properly to heed the risk that he would take his own life, despite his diagnosis of bi-polar disorder with psychotic features, a prior history of suicide attempts, and despite Johnny being subject to a Community Treatment Order which gave the Trust the power to recall Johnny to hospital quickly if his health was in danger.
As the Coroner found, Johnny’s mental state declined significantly following his discharge from hospital on 14th December 2023 and the signs of this were apparent by 8th January 2024. Despite seeing or speaking to him on 4 occasions after that, his Community Care Coordinator, employed by Rushcliffe Local Mental Health Team (RLMHT), told the Court she did not consider Johnny was at risk of suicide. Her evidence on this point was rejected by the Coroner who found she failed to heed clear signs of a real and growing risk that Johnny would take his own life. Although charged with his care, she and his responsible clinician did not recognise that Johnny’s mental condition was deteriorating nor properly listen when he told them he had suicidal thoughts. They failed to consider that he should have been recalled to hospital under his Community Treatment Order; neither did they address other treatment options open to them which would have protected him, including seeking to persuade him to accept voluntary readmission or detaining him under the Mental Health Act. They failed to see or heed the signs until it was too late.
The Coroner was critical of the Trust’s standard of record keeping as well. Risk Assessments and Care Plans were not updated when they should have been. It also emerged at the Inquest that his Community Care Coordinator did not receive training in Suicide Risk from Nottinghamshire Healthcare NHS Foundation Trust until AFTER Johnny had taken his own life.
Caroline Saxton, Johnny’s mother said:
“Johnny was so brave and tried so hard to fight his difficulties until life became too much for him. He was so, so loved by so many people. Whilst I recognize the difficulties which face those charged with the care of mentally ill patients in the community, Johnny was badly let down by Nottinghamshire Healthcare NHS Foundation Trust and I cannot help but feel that this cost him his life. I sincerely hope that lessons will be learned by Nottinghamshire Healthcare NHS Foundation Trust and Johnny’s death will not be in vain. I hope that the findings made by the Assistant Coroner today will lead to fundamental changes and will help to safeguard other vulnerable patients in the future. I would not want any other family to have to endure what we have done”.
Julie Walker, Consultant and Solicitor at Rothera Bray Solicitors said:
“Johnny’s family have shown great strength since his death. It has been a devastating time for them and a challenging legal process. I am pleased that the Assistant Coroner recognised that there were missed opportunities by the Healthcare Trust. Making certain that questions were answered, and responsibility was taken during the inquest was the last thing which the family could properly do for Johnny. I hope that they now feel they have some of the justice which they deserve for him and for future patients who access mental health services locally”.
The family wish to express thanks to Philip Turton, Counsel at Ropewalk Chambers, and to Abagail Clarke and Julie Walker of Rothera Bray Solicitors, for their support, expertise and empathy during this difficult time. The family also extend thanks to the Assistant Coroner and his officers for their time, and for the care and attention they took in closely examining the circumstances which led to Johnny’s untimely and tragic death.
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Julie Walker, Consultant and Solicitor, Rothera Bray Serious Injury and Inquest Team, j.walker@rotherabray.co.uk
