Mental health service warned about ongoing risk following Essex man’s death

Jamie took his own life in June 2022, hours after being discharged from Basildon Hospital where he had attended A&E asking to be admitted for his own safety.

The inquest found the assessment carried out of him in A&E was “inadequate”, and that there were also a series of “significant and repeated failures” in the care and treatment provided to Jamie in the six months prior to his death. The Coroner found that the series of failures and missed opportunities by EPUT amounted to “neglect”, and this directly contributed to Jamie’s death.

In his prevention of future deaths report, issued on 29 October 2024, Area Coroner Sean Horstead has asked EPUT to address the absence of effective, formal compulsory training for clinicians on the Dual Diagnosis pathway. This is a combined approach to care for mental health patients, who also struggle with substance misuse.

He also said that he was concerned that the EPUT First Response Team lacks “a robust and reliable system” for managing its caseload and this contributed to the significant failure not to hold a Multi-Disciplinary Team Meeting. This meeting would have been a chance for experts to discuss Jamie’s treatment and provide him with appropriate care.

The Coroner has given EPUT until 23 December 2024 to formally respond to his report.

Jamie’s mother, Carolyn Claydon said:

“Losing Jamie was devastating. We miss him every day and are still traumatised by how badly he was let down by those who should have been providing him with the treatment he desperately needed, and who should have kept him safe.

“We are grateful to the Coroner for considering Jamie’s case so thoroughly. It is heartbreaking to see in such detail, just how many parts of the system meant to protect Jamie, completely failed.

“We hope that EPUT takes action to ensure something like this can never happen again.” 

Leigh Day solicitor, Lily Hedgman added:  

“Jamie’s death was the result of multiple systemic failures and this report from the Coroner marks an important moment in attempting to ensure that no other family has to suffer the avoidable loss of a loved one in similar horrifying circumstances.

“It is hoped that EPUT will seriously reflect on the lessons to be learned from catalogue of terrible failures that led to Jamie’s death, and ensure that the most vulnerable people in Essex receive the level of care they deserve.”