Carer’s response inappropriate and care provider ‘aggravated situation’ before balcony fall death of Jamie Cole, 25, inquest concludes

The coroner at the inquest into Jamie’s death returned a narrative conclusion whilst criticising those who were responsible for caring for Jamie at the time.   

Jamie, of Bristol, died following the fall from the balcony at Hotel Sol in Tenerife on 14 January 2023. 

He had autism and had been on holiday in the company of a carer provided by Bristol care provider Accomplish. 

However Avon Coroners Court heard that on the day he died, Jamie had an argument with his carer. He had messaged by text to Accomplish to let his care supervisor know of his intention to take his own life, but the supervisor had responded “Stop being silly”. 

Jamie being accommodated in a room on the hotel’s fifth floor, while his carer was staying in a room on the opposite side of the hotel, when it was known that heights were a trigger for potentially suicidal thoughts, was highlighted as an issue that could have been a risk to his wellbeing. 

Coroner Dr Peter Harrowing was also told that the arrangements for the holiday had been put in place at short notice after Jamie had experienced a happy and successful trip to Portugal, also in the company of a chaperone provided by Accomplish, in December 2022.  

The Tenerife holiday was organised and approved with only 24 hours’ notice to Accomplish supervisors, which Jamie’s mother Martine Cole said meant a risk assessment was rushed and not carried out effectively. The Coroner noted that the risk assessments in relation to the holiday were deficient. 

In a statement read to the court, Ms Cole said Accomplish had begun caring for Jamie in January 2020 after he was discharged from hospital on to a Conditional Treatment Order (CTO) under Section 117 of the Mental Health Act 1983. The care was commissioned and funded jointly by North Somerset Council and the NHS. He was eventually discharged from the CTO and began a Learning Development course and worked part time in a shop and volunteered at his community cafe. He was independent, but carers lived with Jamie 24/7 in their own room and he relied on them heavily for support. 

In August 2022 Jamie had travelled alone to Clifton Suspension Bridge where he called police for help and also telephoned his care supervisor to let her know he did not intend to take his life. 

Following the incident, a review was undertaken and Jamie’s medication was reduced. In December 2022 a specific support plan was prepared which guarded against restraints and use of seclusion, yet Jamie was never under a Deprivation of Liberty Order to legally authorise these restraints. It advised that if Jamie showed signs of suicidal ideation he should not be redirected to his room. At times of stress, if a person could not be with Jamie in person, he needed someone on the phone to ensure he had some contact. 

The risk assessment for the Tenerife holiday described trigger points for Jamie and listed signals of his stress which included pacing and repetitive questioning. It listed the risk to him of heights, and the potential consequences of him being in extreme stress.  

The risk assessment stressed the importance of not expressing anger towards Jamie.

On 9 January 2023 a rolling risk assessment was completed, listing Jamie’s triggers as “loss of money, loss of medication, disagreements with staff, suicidal ideations, self-harm”.

In her statement Ms Cole said Jamie would also make sure that he did not make bookings where he would have access to balconies.

On arrival at the hotel, it became clear that Jamie had been allocated a room on the fifth floor while his carer was staying on the opposite side of the building.

Ms Cole's statement said that Jamie would not have agreed to staying in a fifth floor balcony room if he had a choice, but would have accepted staying in the room for fear of staff being cross with him. She believed Jamie and his carer should have had adjoining rooms.

On the day that Jamie died, his grandmother received a call from Jamie, upset that he had had an argument with his carer over the cost of a meal. He interrupted the call to take a call from his care supervisor in the UK, then called his grandmother again, this time annoyed and upset, saying the supervisor had been angry with him. His grandmother tried to calm Jamie down and secured a promise form him that he would not leave the hotel.

The court heard that a series of text messages were exchanged between Jamie and his carer in the UK and his carer in Tenerife.

An internal investigation at Accomplish concluded that the messages had been unprofessional. Jamie had messaged his UK carer supervisor to express his intention to take his life, to which she responded “Stop being silly”.

The court heard that the UK carer supervisor had told the internal investigation that she was not aware of a risk assessment that should have been followed during the trip.

Giving his conclusion, coroner Dr Peter Harrowing, said: “Jamie, who had a number of mental health conditions, was on holiday in Tenerife with a support worker. Following a  a disagreement with the support worker, he returned home dysregulated and jumped from a balcony. He died from multiple injuries.”

The Coroner found that Jamie’s intention could not be established. The Coroner also found that the response from staff responsible for Jamie's welfare was inappropriate and that the response from senior staff aggravated the situation. The incident was also not reported to more senior staff when it should have been.

In a statement given following the inquest, Jamie Cole's mother, Martine Cole said:  

“My Jamie was the most joyful, bubbly person you could know. He was open and honest, loving and kind. He was a precious, most loved member of our family.  

"He was funny, passionate and one of a kind. 

“His autism meant he could easily become upset, but the triggers that presented a risk to his wellbeing were well documented and well known to those who supported him.

“I am grateful to the coroner for taking two days to examine what happened to Jamie before he lost his life when he was on holiday in Tenerife in the company of a carer from Accomplish.

“However, I will never fully understand how my son went on holiday happy and healthy but never came home.  

“I can only hope that the inquest into Jamie’s death has reminded care companies of their very grave responsibility towards those individuals they chaperone, and to always take huge care over support plans and risk assessments.

“We have lost our precious Jamie forever, but I believe he should still be with us.” 
  
Martine Cole is represented by human rights team solicitor Claire Hann of law firm Leigh Day.

Claire Hann, solicitor at Leigh Day said:

“I would like to pay tribute to the bravery and dignity that Martine Cole has shown in the almost three years since the death of her son, Jamie.

“The court has heard a chaotic story of the hours that preceded Jamie’s death. The court has heard, and the coroner has found that the risk assessment planning was deficient, the response from staff responsible for Jamie's welfare was inappropriate, that the response aggravated the situation and it was not reported to senior staff.