A “smart, lovely and kind” man who struggled with depression and bipolar disorder for most of his life was able to take his own life at a mental health facility despite being deemed at risk of suicide, a jury has heard.

Jonathan O’Shea died after he hanged himself at Littlebrook Hospital, in Dartford, on March 2, 2023.

An inquest into his death heard this week that the 37-year-old was admitted to the hospital under section 2 of the Mental Health Act after he was arrested and taken to Bridgewater police station, in Somerset.

It came after he sent an email to officers claiming he wanted to harm himself and others and that he had sexually abused children – which was later found to be false and part of a psychotic episode.

Jonathan, who was known to his friends as JJ, was diagnosed by his GP with bipolar and depression, something he’d been prescribed medication for, and had attempted to take his own life on several occasions.

He also had PTSD as a result of trauma following a sexual assault.

In a statement read to the court his mother, Anne Power, from Sevenoaks, said: “Jonathan had a long history of mental health after he was sexually assaulted in prep school.

“He was a smart, lovely, and kind man. Prior to his death, he’d been staying with a friend when he’d become unwell and stopped taking his medication.”

After his arrest, Anne had asked if the mental health team caring for Jonathan could continue its help for her son in Somerset. However, this was refused as Jonathan was registered with a Kent GP.

He was transferred to the Pine Wood ward at Littlebrook Hospital on February 24, 2023.

Ms Power stated that, despite police noting that Jonathan was paranoid and at risk of suicide, she never received contact from the hospital to discuss his care, which she thought was “unusual” due to meetings she’d had at other mental health facilities over the years about his treatment.

Ms Power visited her son on three occasions before his death and noted that on the final occasion, Jonathan was crying and visibly upset. He was giving his mum what later became his “final goodbyes”.

Helen Wright was the deputy ward manager on the morning of his death.

Speaking about Mr O’Shea’s records she said: “I knew Jonathan had a mental health history and that he was on medication but I can’t say if I knew 100% that he’d previously tried to take his own life. I did not know about his previous attempts.”

Ms Wright, who’s worked at the hospital since 2018, explained that Mr O’Shea’s history had never been conveyed to her during the handover which takes place between shifts on the ward.

On the evening of March 1, 2023, it was observed that Jonathan and several other patients on the ward were in the lounge watching The Godfather until 12.20am the following morning.

After this patients were told to retire to their rooms and begin settling down for bed where they’d be observed by staff.

Jonathan was down to be observed hourly, the least intensive and intrusive observation procedure on the ward.

Other observations include patients being observed four times an hour, six times an hour, being in constant eyesight of staff, and finally in constant eyesight and arm’s reach of staff.

During the second day of the hearing Dr Rachel Daly, a consultant psychiatrist at Littlebrook Hospital, explained all patients are put under observation for four times an hour when they first arrive at the facility as protocol.

Three days after Jonathan had been admitted, on February 27, 2023, his observations had been dropped from four times an hour to just once an hour.

When giving evidence today, both Ms Wright and Dr Daly said they had no recollection of that discussion taking place – the decision had been noted on Jonathan’s notes on the ward’s “not user-friendly” system by a trainee doctor after the alleged discussion with Ms Wright and Dr Daly.

After being presented with this evidence Helen Wright said: “A junior doctor would have the authority to drop the amount of observation Jonathan received but usually there would have been more discussion and documentaton.”

Jonathan was noted as being in his bedroom and awake at 1am and 2am – where he is said to have been standing in the middle of his room - 3am and 4am until Ola Adebaya, who worked for Littlebrook Hospital for four years, noted that when he went to observe Mr O’Shea at around 5.10am he saw the bedroom light on but his en suite bathroom door shut.

Mr Adebaya, who is no longer employed by the trust, was unable to be tracked down by the coroner’s office to speak in person in court and so his statement had to be read out.

It said: “I believed that Jonathan was in the toilet and went on to continue my observations of other patients.

“About 20 minutes later I returned to Jonathan’s room and saw that his room was unchanged when I looked through the window on his door and the bathroom door was still closed.

“I gained access to Mr O’Shea’s room with my fob and knocked on his bathroom door. There was no answer so I opened the door and saw Jonathan hanging.”

“I usually take charge and I feel like I didn’t behave as I usually would do as a nurse in that moment.”

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Mr Adebaya then explained he ran to staff for help, instead of raising the alarm, and did not check for breathing before he did this.

Once staff were alerted to the situation 999 was called, as was the duty doctor who ordered Mr O’Shea to be cut from the ligature and for CPR to be started.

It was later revealed to the jury that it took two to four minutes to cut Jonathan down, and it wasn’t until eight-and-a-half minutes after he was discovered that CPR was started. After 11 minutes defibrillation was attempted.

When the alarm was raised, Ms Wright was taking a break.

She was called back inside immediately and agreed that the staff were “shocked, there was panic and the ward was chaotic”.

Through tears, she said: “I usually take charge and I feel like I didn’t behave as I usually would do as a nurse in that moment.

“I fell apart from a human aspect, not because I didn’t know how to do my job.”

Paramedics arrived at the scene around 5.45am and complained it had taken them five minutes to gain entry to the hospital as there are no reception staff during the late shift.

Jonathan was declared dead at 6.04am on March 2. The coroner confirmed his death to be caused by hanging.

The inquest continues tomorrow.

Kent and Medway NHS and Social Care Partnership Trust has been approached for a comment.