Paramedics struggled to access mental health unit where man who felt like 'prisoner' took his life
A 37-year-old man was able to take his own life in a secure mental health unit, despite a known history of suicide attempts, an inquest has heard.
Jonathan O’Shea from Sevenoaks, Kent, died at Littlebrook Hospital in Dartford on 2 March 2023, while being detained under the Mental Health Act.
Mr O’Shea had been admitted to the 16-bed facility six days earlier, after being arrested by police in Somerset, where he was staying with a friend.
A healthcare assistant conducting hourly patient observations on the night shift found Mr O’Shea unconscious in his bedroom at approximately 5.45am, North West Kent Coroner’s Court was told.
An inquest into his death resumed this week in Maidstone, with a jury selected on Monday.
“Jonathan had a long history of mental health issues and had not taken any medication or vaccines for the past 12 months”, his mother Anne Power told the court in a written statement.
The inquest heard Mr O’Shea had first tried to end his life while at secondary school.
There were at least two further suicide attempts in the UK and South America.
His mother last saw her son in person on 29 February 2023, while visiting him at Littlebrook Hospital, when he was “very upset”.
Ms Power said: “Despite him being a patient for six days and me visiting on three occasions, I was never spoken to by any of the clinicians or asked any questions.
"This was unusual compared to other [mental health] facilities, when I had always been included in Jonathan’s rehabilitation."
Clinicians at the Kent unit had decided he only needed to be checked by staff every hour, despite the mental health crisis team in Somerset assessing he was at “high risk of suicide”, the inquest heard.
The nurse in charge on Pinewood Ward on the night of Mr O’Shea’s death, Helen Wright, was asked by Steve Killalea KC, representing the family, whether she had been aware of his “considerable history of suicide attempts”.
“I was unaware, from what I can remember”, she replied. Asked if she was aware he’d been deemed at high risk of suicide by the NHS team in Somerset, she told the court: “I was unaware”.
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The inquest heard that on discovering Mr O’Shea unconscious in his en-suite bathroom staff did not start CPR efforts for eight minutes.
A defibrillator was not used for more than 11 minutes.
Paramedics struggled to gain access to the facility, according to ambulance service notes read to the jury.
“They were quite surprised that it had taken around five minutes once they arrived at the building until they were granted access. It appears they struggled to gain entry to the building”, police sergeant Daniel Horsley, of Kent Police, told the court.
The response by the ward staff was “chaotic”, according to nurse in charge Helen Wright, with emergency alarms not activated.
A formal risk assessment for Mr O’Shea had not been completed by clinicians until the day before he died, the inquest heard, something that was “very unusual” and “concerning”, Ms Wright told the court.
Littlebrook Hospital is operated by Kent and Medway NHS and Social Care Partnership Trust.
The inquest continues.
Organisations offering help and support:
Samaritans provide round-the-clock support for people of any age when they need it most. You can call them 24 hours a day on 116 123. They also have tips if you are concerned about someone you know, and advice if you're struggling yourself.
Mind provides advice and support to help anyone experiencing a mental health problem. They also campaign to improve services, raise awareness and promote understanding. You can call them Monday to Friday between 9am and 6pm on 0300 123 3393. You can also text them on 86463.