Coroner Demands Accountability Over Mental Health Death

A coroner has sought explanations from a mental health service concerning the death of a man who was discharged from hospital. Jamie Harding, 31, died in June 2022 after falling from a window at his residence, mere hours after he had sought assistance at Basildon Hospital while described as being “in crisis.” Area coroner Sean Horstead determined that “significant and repeated failures” by the Essex Partnership University NHS Foundation Trust (EPUT) contributed to Mr. Harding’s death. Paul Scott, EPUT chief executive, stated: “I am sorry for the mistakes that were made in Jamie’s care.” An inquest held in April established Mr. Harding’s cause of death as multiple injuries resulting from a fall from height. In a Prevention of Future Deaths Report, issued on Thursday, the coroner concluded that “neglect” by EPUT directly played a role in the fatal fall. Mr. Harding had previously been under EPUT’s care between 2017 and 2020, during which he was prescribed anti-psychotic medicine. After a period of disengagement from the service, by November 2021, he was “hearing voices, experiencing paranoia, and reporting his medication was not working.” The report indicated that EPUT assessed Mr. Harding in January 2022 and put a care plan in place; however, a “series of significant and repeated failures” meant it was not fully implemented. On 3 June 2022, Mr. Harding attended Basildon Hospital, having not slept for three days and exhibiting “extreme paranoia and psychotic symptoms.” A mental health consultant concluded that hospital admission would be beneficial for him, but he was ultimately sent home, as documented by Mr. Horstead. The coroner further noted: “Within hours, Jamie took his own life, having fallen a significant height from a window at his home.” Mr. Horstead has given EPUT 56 days to detail the actions it will take to prevent similar deaths in the future. He emphasized that improvements are necessary for EPUT’s first response team, as evidence revealed it lacked a “robust and reliable system” to manage its caseload. Speaking after the April inquest, Carolyn Claydon, Mr. Harding’s mother, described her son’s death as “devastating.” She added: “We miss him every day, and those of us who were present when he died continue to be traumatised by what happened.” “While nothing can be done to change those events and bring Jamie back, I hope that EPUT takes steps to learn from the circumstances of his death.” Mr. Scott conveyed his deepest condolences to Mr. Harding’s loved ones. He also stated: “We are continuously working with families, staff and partners to drive the transformation of mental health services so that all patients always receive the high-quality and personalised care they rightly deserve.” For news updates from Essex, follow BBC Sounds, Facebook, Instagram, and X. Copyright 2024 BBC. All rights reserved. The BBC is not responsible for the content of external sites. Read about our approach to external linking.