18 year old takes his own life following mental health failings

Dean Wilson Solicitors LLP have been acting on behalf of the estate of Archie Jesty who sadly took his own life on 1 May 2022, following failures by mental health services.

Over a period of 8 months preceding his death, over a dozen referrals and attempts were made to seek support for Archie from mental health services. Ben Davey, Senior Chartered Legal Executive, of Dean Wilson Solicitors provided representation and support for the family at the Inquest to obtain answers about the lack of treatment provided to Archie. The Coroner as part of the proceedings found that there had been shortcomings in Archie’s care, and that these had contributed to his death.

Background

Archie Jesty was born on 23 January 2004 and lived with his family in Liss, Hampshire. Archie studied at Midhurst Rother College and had been one of the College’s top performers at GCSE Level. He was a member of the college orchestra and helped to teach the younger students whilst he was in the sixth form at the college. Archie was intending to go to University in Autumn 2022.

Archie’s parents and college first became aware of his struggles with his mental health on 2 September 2021, when he told a friend he was feeling low and felt he may take his own life. The college was then informed about this interaction through a friend of the parent of Archie’s friend. Archie’s college did not provide any guidance to him further than issuing Archie with safeguarding advice and telling his parents to call 999 or attend A&E if Archie expressed suicidal feelings.

On 7 September 2021, his first day of Year 13, Archie again expressed he was experiencing low moods and had made plans for his suicide, this time to staff at the college. Archie’s father took him from the school to A&E, where Archie was admitted overnight, and the next day he was assessed by CAMHS (Child & Adolescent Mental Health Services) via telephone and referred to YES (Youth Emotional Support Service), which at the time had a 7-month waiting list.
On 20 January 2022, Archie took his private journal to the college which documented how he had been feeling. Further unsuccessful referral attempts were made, and his mental health continued to decline over the coming months.
By 24 March 2022, it was clear that Archie was incredibly unwell, and his family actively made attempts to seek help for him. Over the next week, Archie presented at A&E twice, had 2 GP appointments, and contacted iTalk and Safe Haven to seek a mental health assessment. Archie’s mother contacted Archie’s college imploring them to help, as they had exhausted all avenues available to them to get Archie support for his mental health. Archie’s college contacted the Local Authority, which led to a mental health assessment on 1 April 2022, after which Archie was referred to the Crisis Resolution and Home Treatment Team (CRHTT).

Despite having made and expressed plans to take his own life, the Crisis Resolution Team felt that Archie did not need daily support.

Four days before Archie took his own life, he was placed on a “green” rating, which meant that the Crisis Team considered him safe for discharge. Those present at the inquest heard how the Designated Safeguarding Lead at Midhurst Rother College, wrote to the Crisis Team imploring them to extend their support, and that Archie still had the “same plans for ending his life”. The principal of the college additionally wrote to the Crisis Team, pleading “he is at extremely high risk of suicide”, and “I think he needs more time and I worry about the potential outcome if this doesn’t happen.”

By way of response, the Crisis Team informed the school that they would get back to them that they “only work with people for 4 weeks as a rule”, and that they did not “foresee that it would be possible” to continue providing support for Archie. Members of the crisis team that visited Archie after concern was raised by the college reported at the Inquest to not have been shown the college’s email and said that they did not feel Archie was at risk to himself.

On 1 May 2022, Archie took his own life at his home.

Inquest

During Archie Jesty’s inquest, the Coroner, Mrs Joanne Andrews, heard testimonies from Mr and Mrs Jesty, staff of Midhurst Rother College, the Child and Adolescent Mental Health Services (CAMHS), and the Southern Health NHS Foundation Trust, as well as from the Youth Emotional Support Service (YES). Mrs Joanna Andrews found that failures to undertake a formal diagnosis, document a safety plan, or risk assessment, along with insufficient communication between the services, contributed to Archie’s death.

Ben Davey (Senior Chartered Legal Executive, Dean Wilson Solicitors) acts for the family and says: “It is clear that Archie was badly let down by those that were supposed to keep him safe. He was passed between services, with no one accepting overall responsibility for his care. It was clear that he wanted to engage with treatment, and needed some help to get through a difficult period in his life. Unfortunately, this was not provided to him.

It is important that the Coroner has recognised the failings, and that these contributed to Archie’s death. The family would like a review of services to ensure that this can never happen again.”

Speak with our team for support through an inquest

The Dean Wilson Solicitors team are specialists at guiding families through Inquests. Ben Davey acted for the family in this matter under a no win no fee style agreement. Please visit our inquest page or contact us today at 01273 249200 if you would like to speak with our team.