Coroner demands answers over mental health death

A coroner has demanded answers from a mental health service over the death of a man sent home from hospital.

Jamie Harding, 31, died after falling from a window at his house, hours after he sought help at Basildon Hospital while "in crisis" in June 2022.

Area coroner Sean Horstead said "significant and repeated failures" by Essex Partnership University NHS Foundation Trust (EPUT) led to Mr Harding's death.

EPUT chief executive Paul Scott said: "I am sorry for the mistakes that were made in Jamie's care."

Mr Harding's cause of death was given as multiple injuries resulting from a fall from height at an inquest in April.

In a Prevention of Future Deaths Report, published on Thursday, the coroner said "neglect" by EPUT directly contributed to the fatal fall.

Mr Harding was first under the care of EPUT between 2017 and 2020 and prescribed anti-psychotic medicine.

After a period of disengaging with the service, he was "hearing voices, experiencing paranoia, and reporting his medication was not working" in November 2021.

The report said EPUT assessed Mr Harding in January 2022 and put a care plan in place for him, but a "series of significant and repeated failures" meant it was not fully implemented.

Mr Harding attended Basildon Hospital on 3 June 2022, having not slept for three days and experiencing "extreme paranoia and psychotic symptoms".

A mental health consultant concluded he would benefit from being admitted to the hospital, but ultimately he was sent home, Mr Horstead wrote.

"Within hours, Jamie took his own life, having fallen a significant height from a window at his home," the coroner added.

Mr Horstead gave EPUT 56 days to explain how it would take action to prevent a similar death in the future.

He said improvements must be made on EPUT's first response team as evidence showed it lacked a "robust and reliable system" to manage its caseload.

Speaking after the inquest in April, Mr Harding's mother, Carolyn Claydon, said her son's death was "devastating".

"We miss him every day, and those of us who were present when he died continue to be traumatised by what happened," she said.

"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 said his deepest condolences remained with Mr Harding's loved ones.

"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," he added.

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