The death of a teenager, who hanged himself in a Plymouth woodland, was wholly avoidable say his family. 

John Taylor Partridge, 17, was admitted to hospital after taking an overdose but was later assessed as being ‘low risk’ and discharged – only to be found hanged in Budshead Woods on Monday, March 17 2014.

Yesterday, the Assistant Coroner for Cornwall, Plymouth and Devon, Mr Andrew Cox, delivered a conclusion of suicide at Plymouth Coroner’s Court.

In his summary, Mr Cox said he would be writing to Health Secretary Jeremy Hunt about the lacuna in the law, the gaps in definitive protocol in whether to treat 16 and 17 year olds under the Children’s Act or the Mental Capacity Act.  

He also said that the local health trusts should offer guidance for local practitioners so that any confusion in relation to the care and treatment of 16 or 17 year olds would be clearer.

Following the inquest, John’s mother Sandy Partridge said: “John was a particularly vulnerable young man who fell through the cracks of the healthcare system.

“Despite a history of mental health issues, our teenage son was able to discharge himself from the care of professionals.

“John was assessed as an adult, treated as an adult and ultimately discharged as an adult, when in fact he was a sensitive, defenceless young man, not yet 18, who posed a high risk to himself.

“We believe there is a grey area in mental healthcare that needs to be examined and resolved in order to prevent any more young people slipping through the net.”

John, of Ernesettle, was admitted as an emergency to Derriford Hospital in Plymouth on Friday, March 14 2014 after taking an overdose of promethazine tablets. He had blood on his clothes having cut his wrists with a razor blade. 

He was dealt with at the medical assessment unit of the hospital where a consultant identified him as being at high risk of further self-harm. The plan was to refer him to psychiatry with a view to sectioning under the Mental Health Act.

There had been at least one previous suicide attempt, and John had been under the care of CAMHS in Plymouth (Child and Adolescent Mental Health Services) for several years. He had previously been diagnosed with autistic spectrum disorder and mild learning difficulties, and at the time of his death he was on anti-depressants prescribed by his GP.  

The following day, Saturday, John absconded from the hospital and police were called to find him and bring him back. Because it was the weekend, the CAMHS Community Outreach Team of Livewell Southwest – previously Plymouth Community Healthcare – was not available. 

He was seen by a junior doctor – who was on rotation and had very little experience in mental health – and a mental health nurse. They assessed John and even though he wasn’t very co-operative and not answering questions, they concluded that he had capacity, that he could self-discharge and that he was not at risk of immediate self-harm.

He had no advocate at the meeting, no family member and no clinician dealing with adolescents – the doctor and nurse present worked in adult psychiatry. The junior doctor called a CAMHS consultant for advice, however she decided that the consultant did not need to assess John in person, medical records show no details of how the conclusions were arrived at and what was involved in the assessments carried out and they did not carry out a Mental Health Act assessment.

All of the assessments and decision making took place without mum Sandy in attendance, so relying on the expertise of medical staff she felt she had no choice but for John to return home.

However, tragedy struck on Sunday when John left his parents’ home and never came back.

Sandy Partridge said: “John should never have been discharged – we believe his death was avoidable.

“How ironic that on the day of the junior doctors’ strike, we have received the conclusion in an inquest that concerned a junior doctor carrying out an assessment on a patient which led to his discharge following which John ended his life.

“There wasn’t a full team working in mental health during the weekend that John was admitted, and our belief is that there is a gaping black hole in the current mental health service, and we support the Government’s initiative for a seven day service. 

“In John’s case, if the junior doctor had had more support and guidance, John would probably not have been discharged from hospital following which he ended his life.

“Although any changes will not bring John back to us, we don’t want to see any more families go through the pain and suffering that we have experienced and continue to experience on a daily basis.”

Assistant Coroner Mr Cox, in his findings, said that:
•    there was no record of how the assessments were carried out and how the conclusions were arrived at
•    there was no evidence that the safety and welfare of John was paramount as per the Children’s Act
•    no clear plan was made with Mrs Partridge upon discharge eg. in the event that John wished to leave and disregard parental instruction
•    there was a limited CAMHS presence on the weekends and that this should change

Mr Cox was assured by the Trust representatives that funding was now available and that the advertising for recruitment for practitioners to work on weekends had already started.

John’s family were represented by barrister Mamta Gupta of No5 Chambers, who in turn was instructed by Frances Morgan and James Snell of Wolferstans Solicitors.

For media coverage of the case please click links below – 

The Guardian – Coroner seeks answers over hospital treatment of teen who killed himself
The Sun – Suicidal teen killed himself just hours after inexperienced junior doctor let him discharge himself from hospital
The Mirror – Coroner writes to Jeremy Hunt over teen suicide death after he was discharged from hospital at weekend
Plymouth Herald – Coroner says system has to change after vulnerable Plymouth teen took his own life

CLICK HERE to view Mamta Gupta’s profile