John Richard William JONES · Prevention of Future Deaths report

On 22 April 2016, one of my assistant coroners, Richard Brittain, commenced an investigation into the death of John Jones, aged 48 years. The investigation concluded at the end of the inquest yesterday. I made a determination as follows.

John Jones died instantaneously when he jumped in front of a moving train at approximately 7am on Monday, 18 April 2016 at West Hampstead Railway Station. However, the state of his mental health at the time meant that he lacked the necessary intent to categorise this as suicide.

Mr Jones was a patient of ████████, consultant psychiatrist, who arranged his admission to the Nightingale Hospital, a private hospital specialising in mental health, on 22 March 2016. Mr Jones was still being treated by ████████ at the Nightingale at the time of his death.

I heard at inquest that, during his month long residence at the Nightingale, Mr Jones declined to engage with any of the 35 hours per week of group therapy on offer. He did see his consultant psychiatrist for a one to one session three times a week, and he went for a short walk with his parents most days.

However, for the majority of his time in hospital, this extremely bright and able but very unwell man, simply stayed in his room alone.

He engaged with nurses who popped in to see him on a polite but only ever superficial level. Sometimes he used his computer, but he did not even come out for meals with the other patients. He had a good appetite, but asked for meals to be brought to his room, which they were.

This seems a very sub optimal therapeutic environment, most particularly as Mr Jones’s psychiatrist said that the reason for admitting him to hospital was to enable him to access the therapy on offer. I appreciate that Mr Jones himself declined the therapy, but the difficulty he had in accepting help was surely part and parcel of the reason for this episode of mental ill health, and had to be addressed.

Whether a patient’s engagement is made a condition of stay at the hospital, whether it is secured by offering a different form of therapy e.g. on a one to one basis, or whether there is some other way of ensuring better treatment, is of course a matter for you.