Nottinghamshire man, 24, 'badly let down' by NHS before tragic fatal crash

Johnny Baker
-Credit: (Image: Rothera Bay)


A Nottinghamshire man who had a long history of mental health struggles was "badly let down" by the NHS before he took his own life, his family have said. Johnny Baker, from West Bridgford, died on January 17 after being hit by a bus.

An inquest found the 24-year-old's suicide risk was not properly assessed by healthcare workers after a "significant and ongoing deterioration" in his mental health at the beginning of the month. A coroner said recalling him to hospital would likely have prevented his death.

Nottinghamshire Healthcare NHS Foundation Trust (NHFT), which runs mental health services in the county, "apologised unreservedly" for its "shortcomings". Mr Baker's mother, Caroline Saxton said: “Johnny was so brave and tried so hard to fight his difficulties until life became too much for him.

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"He was so, so loved by so many people. Whilst I recognize the difficulties which face those charged with the care of mentally ill patients in the community, Johnny was badly let down by NHFT and I cannot help but feel that this cost him his life."

She added she hopes that lessons will be learnt by the trust so her son's death "will not be in vain". Mr Baker had a "long and difficult history of mental ill health" with episodes of psychosis and mania, lack of insight and non-compliance with medication, assistant coroner Michael Wall said.

He had been diagnosed with bipolar affective disorder and mental and behavioural disorder due to psychoactive substance misuse, with previous instances of self-harm including a suicide attempt in October. Mr Baker had been involved with both child and adult mental health services and was admitted to hospital as both a voluntary and involuntary patient.

At the time of his death, he was under the care of the Local Mental Health Team and subject to a Community Treatment Order, which enabled healthcare workers to recall him to hospital. Mr Baker presented "very low in mood" after a cocaine binge in the days leading up to his death, said Mr Wall.

He told his care coordinator and responsible clinician that he wished he was dead, but he denied suicidal intent and his risk was assessed as low. Mr Wall said his suicide risk was not adequately assessed.

"No or no adequate consideration was given to the question of whether to recall Johnny under the Community Treatment Order in light of his deteriorating mental health and increased suicide risk," he said.

"If the above failings had not occurred, there is a real possibility (but not a probability) that Johnny would have been recalled to hospital, which would, if it had occurred, likely have prevented his death."

Ifti Majid, chief executive at NHFT, said: “On behalf of the Trust, I once again offer our deepest sympathies to Jonathan’s family and friends and apologise unreservedly for the shortcomings in care identified by the Coroner. We fully accept the Coroner’s findings and will be addressing the concerns raised to improve the quality of care provided to our current and future patients.”

Julie Walker, consultant and solicitor at Rothera Bray Solicitors, which is representing Mr Baker's family, said: “Johnny’s family have shown great strength since his death. It has been a devastating time for them and a challenging legal process. I hope that they now feel they have some of the justice which they deserve for him and for future patients who access mental health services locally”.