A coroner has ruled that he was neglected by the NHS trust
An Essex man who expressed wishes to end his life multiple times but still refused admission to a mental health facility died after being neglected by the NHS trust responsible, an inquest found. 35-year-old Joshua Leader was found dead in his flat in November 2020 – two days after his admission to the facility was refused.
The inquest into his death, held at Essex Coroner’s Court this month, concluded that his death was suicide contributed to by neglect at Essex Partnership University Trust (EPUT), who were responsible for his care. The coroner said there was “a gross failure to provide basic care”, with no detailed safety plan to ameliorate Joshua’s suicide risk.
A decision not to admit Joshua to hospital two days before he died contributed to his death, the inquest found. Joshua, of Wivenhoe, died just two days after his family had taken him to the Lakes Mental Health Hospital to ask for an urgent admission due to their serious concerns about his safety after repeated remarks about ending his life. This crisis point was reached after months of the family trying to secure adequate care and treatment for Joshua.
According to law firm Leigh Day, representing Joshua’s family, the admission was refused despite Joshua’s willingness and agreement to inpatient care. His family feel had care been taken to assess him properly, he would be alive today. The nurse who refused to admit Joshua to The Lakes told the inquest that he had made a basic failure of care, he had made the wrong decision, broke his own processes and admitted he was disgusted with himself.
Joshua’s family told the inquest that they felt he had been failed by EPUT and that they were not listened to and were treated as a “nuisance” by EPUT professionals, despite their longstanding involvement and consent for them to be contacted about his care. They believe that Joshua was not on the medication he needed, despite attempts over many months to get him back on to anti-psychotics
The court heard that Joshua had no proper care or safety plan despite repeated attempts over 12 months to get one put in place and repeated attempts to have him admitted for inpatient care were refused. An independent expert, Dr Mynors-Wallis, told the court that he could not find any clear formulation of the risk Joshua presented in his notes, and that “without a clear formulation of risk, you cannot plan how to reduce it”.
Long history of mental illness
Joshua was found dead in his flat on November 24, 2020. He had a long history of mental illness, including diagnoses of psychosis and schizophrenia, and at the time of his death was living in the community under the care of EPUT psychosis team. His common symptoms of psychosis included a fixation on other mental and physical diagnoses, such as anxiety, which led him to stop taking his anti-psychotic medication.
Joshua’s family recognised them as signs of his psychosis but the inquest heard that they were often taken at face value by members of the EPUT team, with no reference to his medical history or his family’s input, which led to them agreeing to requests to take Joshua off his medication. Joshua moved back to Essex, where his parents live, in July 2019 and was put under the care of the EPUT psychosis team.
Joshua had grown up in Essex and was previously under the care of Essex mental health services from age 16. From July 2019, his family repeatedly requested a Mental Health Act aftercare assessment and plan, which he was entitled to due to his recent detainment under Section 3 of the Mental Health Act. This assessment and plan was never put in place.
He initially coped well in Essex but by around March 2020 his family believe he had stopped taking his medication and his behaviour became very unstable, with increasing paranoia, delusional thoughts and erratic behaviour. He also started to repeatedly express suicidal intent.
By October 2020, there had been delays in progressing Joshua’s medication, and his mental state deteriorated further and he repeatedly talked about ending his life. On October 19 Joshua was referred to the EPUT Home First Team and while under their care he attended an assessment by a consultant psychiatrist where he denied having psychotic symptoms and asked to be taken off anti-psychotic medications, which was agreed by the psychiatrist. This was despite Joshua’s family raising severe concerns with the psychiatrist about the negative impact this was likely to have on Joshua.
By mid-November 2020 Joshua had been convinced to go back onto anti-psychotic medication by his family. After a family friend, a professor of neuropsychology, wrote to the EPUT team Josh was contacted by his psychiatrist but despite repeated requests from his brother to be involved in his care, he was not informed of the meeting and Joshua denied psychotic symptoms and that he needed antipsychotic medication so no prescription was given.
Joshua’s brother, Dan Leader, told the inquest that on November 22, 2020 his family became so concerned for his safety that they took him to The Lakes Mental Health Hospital for an urgent assessment and hoping for an admission. Joshua received an assessment by a mental health nurse who concluded that he was at immediate risk and should be admitted to hospital, he agreed to this and his family welcomed this decision. However, a member of the EPUT Home First Team then joined the consultation and took a different view which led to him not being admitted.
Credit Essex Live
