Death of man under care of mental health trust in Essex was 'avoidable', says coroner
A 35-year-old man's death while under the care of a mental health trust in Essex was "avoidable", a coroner has said.
Joshua Leader was found dead in his flat on 24 November 2020 while under the care of a specialist psychosis team at Essex Partnership University Trust (EPUT).
At an inquest in Chelmsford a coroner concluded Mr Leader's death was suicide contributed to by neglect.
The coroner said there was an "obvious and conspicuous missed opportunity" to prevent the death of Mr Leader who had a long history of mental illness.
Following the inquest, the Trust apologised for their handling of Mr Leader's care.
Paul Scott, Chief Executive of EPUT, said: “I am sorry for the mistakes that were made in Joshua’s care and my deepest sympathies remain with his family at this difficult time."
Speaking prior to the conclusion of the inquest, his older brother Daniel said he felt it was "an utterly avoidable tragedy".
Daniel said his family became concerned for Mr Leader and took him to The Lakes mental health hospital in Colchester two days before his death. But the hospital did not offer him a bed at the time.
He told the inquest his brother had reached "crisis point" in November, saying he was not on the medication he needed had no consistent care and was "increasingly talking about ending his life".
He said: "To leave The Lakes on 22 November with nothing but a phone number, having had hopes raised of admission for Josh, was the final straw.
"And with the background I have described was, in our view, catastrophic for Josh.
"We believe Josh's death was avoidable, and had his care and treatment been properly planned and delivered, with family involvement and support, Josh would not have died as he did."
He said EPUT's home treatment team seemed "profoundly disinterested in what we had to say".
He continued: "I was spending those days scrambling trying to find out what was going on.
"I was given phone numbers, I call them, I spoke to two people in the home treatment team, I had to explain everything from first base, all over again. We’ve been through this a thousand times.
"I really felt as if i was a complete nuisance to them. They were trying to get me off the phone. I think my mother has similar experiences.
"I was at the end of my tether. I couldn’t get anyone to listen to me.
"This was like someone coming in with a cardiac arrest and being sent home with an aspirin."
Mr Scott, Chief Executive of EPUT, added: “We are committed to driving continual improvement across EPUT and have made significant progress in recent years, working with patients, service users and their families to transform our services, putting patient safety at the heart of all that we do and ensuring patients receive the right care at the right time to meet their individual needs.”
A public inquiry is currently investigating the deaths of almost 2,000 mental health patients in Essex.
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