A patient at a mental health hospital died in part due to neglect and gross failings by the trust.

Jonathan O’Shea, from Sevenoaks, hanged himself while he was being looked after in the Pinewood Ward at Littlebrook Hospital in Dartford on March 2, 2023.

He was admitted to the hospital on February 24, 2023, after being detained by police under section 2 of the Mental Health Act.

Today, after nine hours of deliberation a jury ruled he “died by hanging contributed to by neglect due to gross failings by the trust.”

They found the hospital failed to do a risk assessment in a timely manner and missed opportunities to liaise with the family.

In an emotional statement read outside court, his mother Anne Power, said: “Jonathan was a highly intelligent, kind, and gentle 37-year-old man, and I miss him dreadfully.

"Jonathan was subject to sexual abuse as a child at his prep school and as a result, he has suffered with his mental health for the majority of his adult life.

“I've listened to three days of evidence of basic failures and mistakes that were made in caring for Jonathan at Littlebrook Hospital under the National Health Service.

“There is a long list of mistakes and omissions on the part of the staff at Littlebrook Hospital.

“The jury returned a verdict of suicide contributed to by neglect and due to gross failings by the trust. I can only hope that some lessons are learnt so that no other family must go through this appalling tragedy.”

“Many things have occurred throughout Jonathan's time at Littlebrook Hospital that have led me to believe that they were careless with Jonathan's life.

“Jonathan was my only son. I feel lonely in the absence of my son. I've never expected to spend the rest of my life without him.”

The court heard earlier this week that the 37-year-old was admitted to the hospital after he was arrested and taken to Bridgewater police station, in Somerset, while staying with a friend.

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 after being sexually assaulted while at prep school.

His mother, Anne Power, described Jonathan as a “smart, lovely, and kind man.”

After the verdict, coroner Alan Blunsdon said: “It has been a record set in the time taken to get to a conclusion which is not a criticism because you’ve been thorough.

“Each and everyone of the aspects you have identified has been or is being addressed by the trust and two outstanding issues are going to be referred back to me.”

Earlier this week the jury heard that Helen Wright, deputy ward manager on the morning of his death, knew Jonathan had a mental health history but “did not know about his previous attempts.”

He was also due to be observed once an hour through the night. At around 5am Mr Adebaya did not see Mr O’Shea in his room but noticed the bathroom door was closed.

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 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 found Jonathan dead.”

On the third day of the hearing, coroner Alan Blunsdon, questioned Graham Blackman, the deputy service director for acute care at Kent and Medway NHS and Social Care Partnership Trust, without the jury.

Mr Blackman, who is based at Littlebrook Hospital, told the coroner about improvements made at the mental health facility following Jonathan’s death.

A Root Cause Analysis (RCA) investigation has revealed the patient was able to suspend himself after removing a panel from the bathroom.

Mr Blackman said: “All the other wards now have tamper-proof screws installed in them as it is possible other wards had the same issues.

“The panels in the en-suites are reviewed every time maintenance work happens in them. They are checked on a monthly basis.”

The RCA report also highlighted that the therapeutic observations were not accurately completed at 5am by health care assistant Ola Adebaya.

He did not call Jonathan’s name or enter his room when noting the bathroom door was shut which lead to a delay in finding him.

Mr Blackman said: “According to policy if you can’t see the patient you must go in the room. Mr Adebaya should have gone in the room when Jonathan wasn’t seen.”

The RCA also confirmed that Jonathan’s history was not transferred into a risk assessment.

These should be completed when a patient arrives on a ward, in Jonathan’s case this did not happen until the day before he died, on March 1, several days after he was admitted.

The coroner said a “very good letter” accompanied the Section 2 order that transferred Jonathan from the care of the mental health team in Somerset to the professionals at Littlebrook Hospital which said he was at a risk of suicide. This information was not transferred to the nurses looking after Mr O’Shea.

Mr Blackman said: “The admitting nurse should have made this into a risk assessment, I don’t know why this wasn’t done.”

In April 2023, new directors and managers were appointed for the service to look into the quality of the ward to ensure risk assessments and appropriate paperwork was completed.

When asked what went wrong, Mr Blackman said: “It is a difficult question to answer, it was human error to begin with and then there was an oversight until it was picked up on March 1.”

The coroner called the error “appalling”.

Mr Blackman also said the hospital was very short staffed at the time of Mr O’Shea’s death but today the facility is better recruited.

For confidential support on an emotional issue, call Samaritans on 116 123 at any time or click here to visit the website.

A lessons learned meeting took place following the death which included the highlighting of the health care assistant’s (HCA) error of not ringing the alarm bell as he “did not want to wake other patients”.

In response to this Mr Blackman said:“This shouldn’t happen. If the alarm was sounded other wards also would have been alerted and more staff would have been able to attend and take charge.

“Without this there was shock and panic on the ward which affected the response.”

He then addressed Jonathan’s mum, Anne Power, saying: “We as an organisation give our heartfelt condolences.

“I apologise on behalf of the ward and the organisation for the errors and mistakes and for the pain we caused you.”

Following the inquest, a spokesperson from Kent and Medway NHS and Social Care Partnership Trust said: “We apologise unreservedly to Jonathan’s family and friends for the failings in our care and offer them our heartfelt condolences. The safety of those we care for is our utmost priority and we know we fell short of that on this occasion.

“We are committed to continually improving and doing everything we can to ensure this does not happen again. We acted quickly to address issues we immediately discovered in response to our own investigation, and alongside this we have launched a new suicide prevention strategy which supports improved awareness, training and risk assessments to enable our staff to deliver the best possible care to those who need it.

“We will now carefully consider further findings from HM Coroner to ensure we embed valuable learnings.”