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Finding of neglect against Kent & Medway NHS and Social Care Partnership Trust after young man takes his own life

11 Apr 2024

Dean Wilson are currently acting for a family in an ongoing civil action following an Inquest.


On the 2nd of March 2022, Mr Jonathan O’Shea was able to take his own life whilst sectioned as an inpatient at Littlebrook Hospital. Dean Wilson Solicitors represented Jonathan’s family at the inquest before assistant coroner, His Honour Alan J Blunsdon, at a 3-day jury inquest on 26th – 28th February 2023.

The jury was instructed to provide a narrative conclusion, where they concluded that “Jonathan died by hanging contributed to by neglect due to gross failings and missed opportunities by Kent and Medway Trust”. This conclusion was reached following three days of the jury listening to evidence of the Trusts failings.

The jury at the inquest heard how Jonathan had made several previous attempts on his own life and had a diagnosis of bi-polar and emotionally unstable personality disorder. In the months before his death, Jonathan had been living with a friend in Somerset, where he became increasingly unwell after not taking his medication due to reading conspiracy theories that he had accessed online.

The jury heard how Jonathan had plans to end his life both on his way to Somerset, and during his stay there. Jonathan had sent an email to both his mother and the police, detailing crimes that he was admitting having committed and was subsequently arrested. It was deemed that these crimes were fictitious, and Jonathan had fabricated them due to his severely troubled mental state, and therefore Jonathan was referred to the Somerset mental health team where he was deemed as a threat to himself and at critical risk of suicide. He was then sectioned under Section 2 of the Mental Health Act and transferred to Littlebrook Hospital in Dartford, as his GP was based in Kent.

Findings from the Inquest

It was found during the Inquest that, upon admission, the hospital failed to conduct a risk assessment, which is documented common practice, and a risk assessment was not carried out until 5 days after his admission, the day before Jonathan’s death. Ward psychiatrist, Dr Daly, acknowledged during the inquest that Jonathan was reduced to general observations (once per hour) from Intermittent observations (4 times per hour), whilst acknowledging that Jonathan’s observations should have never been reduced due to his fragile mental state.

The jury heard from police officers who attended the scene after Jonathan death, and a representative for Kent and Medway NHS and Social Care Partnership Trust, that the screws that were used to hold the ceiling panel in place were not anti-tamper screws, and therefore Jonathan was able to remove the panel himself and expose the pipework to create a ligature point. The Trust accepted that this should not have been possible and have committed to undertaking a review of their units.

The investigation carried out by the Trust prior to the inquest established that the protocols had not been adhered to in terms of conducting a risk assessment. The investigation referenced the issues surrounding observations and how the staff were not aware of the patient’s history and reasons for his admission and also the lack of engagement and exploration with the patient and that no collateral information was obtained.

Following the Inquest, Chartered Legal Executive, Ben Davey, says as follows “These tragic series of failings have resulted in the avoidable loss of life of Jonathan O’Shea. These failings have had a devastating consequence on Jonathan’s family, who had hoped for nothing less than him being safe and recovering during his time within this institution. The fact that Jonathan was able to take his own life in a state institution is not a matter that is taken lightly, and the findings of neglect and gross failings at the inquest highlights this. We are glad these failings have been acknowledged and will continue to work with Jonathan’s family in order to ensure that learning is taken from this.”

Contact Dean Wilson for No Win No Fee Legal Advice

Ben Davey, assisted by Natasha Gunn, are now acting for the family in an ongoing civil action.

Dean Wilson Solicitors acted for Jonathan’s family under a no win no fee style agreement. The team can be contacted on 01273 032328 or

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