Coroner rules that Kent mental health services repeatedly failed to implement sufficient safeguarding measures for 24 year-old man before he took his own life

James Victor Amos was 24 when he took his own life in 2019. Today, a coroner ruled that Kent and Medway NHS Partnership Trust and Kent County Council had failed in their responsibility to keep James safe in the run up to his death, despite previous suicide attempts and repeated signs that he intended to harm himself.

James had a history of mental health difficulties and a diagnosis of ADHD, as well as a history of self-harm and suicidal ideation.

The inquest, which ran for seven days, examined the care and support James received in the weeks prior to his death, when he was a known risk to himself.

Evidence heard throughout the inquest centred on repeated actions from the police, James’ mother and James’ doctor in the months before his death to raise concerns over his welfare, yet there was a continued failure to instigate a proper safeguarding plan for him. This included a delay in allocating him a care co-ordinator (one was not allocated until the day before he died), as well as a failure to take into account relevant risk factors when assessing his suitability for detention under the Mental Health Act, and a failure to put an adequate care plan in place.

Although the coroner was satisfied that there was evidence of significant and systemic failings on the part of the Kent and Medway Partnership Trust and failings on the part of Kent County Council, she could not rule that their actions directly caused his death.

She found that prior to his death, James’ risk of suicide had been incorrectly assessed, that he presented a high risk of suicide and that no adequate plan was established to manage his risk. She agreed that there was a delay in allocating him a care coordinator and highlighted that during the assessment under the Mental Health Act his mother was not contacted until after James had been discharged, meaning relevant information was not taken into account. The coroner also agreed that, following James’ discharge from detainment under the Mental Health Act, his mother was not informed of any subsequent plan to keep him safe.

Responding to the coroner’s ruling, James Amos’ family said:

“We are devastated by James’ death. He was an incredibly handsome young man, with the warmest, most twinkly brown eyes and the whitest smile. He had a great sense of humour and made us all laugh with his quirky ways.

“The inquest has heard of multiple failings in the care provided to James. We find it inconceivable that his death could not have been avoided. We believe James wanted support, and would have responded well had he received the care and support that he so badly needed in his time of crisis, and that he would not have died as he did. We will never recover from our loss and James will be forever loved and adored.”

Nancy Collins of Hodge Jones & Allen, who represented the Amos family, said:

“The inquest into James’ death found that he had been failed repeatedly by the mental health teams who should have provided him with the care he required to manage his mental health crisis. The priority for the mental health services involved in this case should have been the implementation of a sufficient safeguarding plan to keep him from harming himself. Sadly, no adequate plan was put in place.

“It has been devastating for the family over the past seven days to hear repeatedly that James did not receive the support he so urgently needed. The repeated failures to properly recognise and respond to the James’ needs will be all too familiar to families of individuals with complex mental health needs.”

“The family had to fight for James when he was alive, but also following his death. They have had to argue over whether an Article 2 inquest was required, whether expert evidence should be heard and whether they should be granted public funding. It is unacceptable that bereaved families continue to face these difficulties in the wake of the tragic death of a loved one.”

Jodie Anderson, a case worker at INQUEST, which advises on state related deaths and their investigation to bereaved people, said:

“James was a young man with autism and ADHD who was in a mental health crisis and needed urgent support. The systems built to respond to this had a duty to protect him but failed to do so. The mental health services missed multiple opportunities to intervene and provide James with the care that he so desperately needed.

“Those involved in James’ medical care accept that they failed to accurately identify his level of risk or provide sufficient steps to meet his needs. Again, we see the devastating effects of mental health services relying on rushed or flawed assessments and further failing to invest in patients care. This failure in communication continues to have devastating consequences, and must be addressed.”

The family was represented by Camila Zapata Beso from Doughty Street Chambers.

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