Jonathan Mark George Hamer · Prevention of Future Deaths report

On 30 August I opened 2023 an investigation into the death of Jonathan Mark George Hamer DOB 7 August 1991, age 32.

The investigation concluded at the end of the inquest on 28 March 2025.

Medical cause of death -
1a Head Injury

The Conclusion was as follows:-

Suicide

Jonathan had been under the care of mental health services for many years and was diagnosed with bipolar affective disorder, for which he was prescribed medications and was under the community mental health team. He was living in supported housing but decided to seek alternative accommodation, also supported, towards the end of 2023. After this was facilitated, a new placement confirmed and his notice period served, he changed his mind but had to proceed with the move during March 2024. He was unhappy in his new accommodation and only stayed for a short number of days, spending time instead with his mother at her home. There were some gaps in his community mental health care due to staff leave and illness in early 2024, although he was seen during March and April. By 16 April he was not responding to telephone calls. At the time of his death he was not taking any of his prescribed medication. On 24 April 2024 he took his life by going onto the tracks in front of a train at ████████, having sent his mother a text message confirming his intentions.

1. There were communication difficulties experienced by Jonathan’s family and his supported housing with the community mental health trust responsible for his ongoing healthcare during the early part of 2024. Telephone calls and text messages were unanswered and there was no communication to confirm that in fact the care co-ordinator had a period of annual leave followed by an unplanned period of sick leave. It was unclear at inquest if service users and their support network had been provided with details of any service changes and current up to date contact details. This meant that important information was not being received by the community mental health team.

2. The community mental health team actively encouraged communication by text messages and emails but had no system in place to intervene when the care co-ordinator was not at work and had left no “out of office” message. There was no system to return or redirect incoming calls or messages so these remained unread and unanswered. Those initiating the communication were unaware that the information was not being received or actioned by the Trust.

3. Jonathan’s case was not “zoned” that is, given a priority coding on the case management system. Therefore, there was no expected period for case review or regularity of expected contact. The multi-disciplinary meetings and supervision meetings when Jonathan’s case was discussed failed to recognise and address this issue. Appropriate zoning and regular reviews are a fundamental part of mental health care and should be embedded and prioritised as part of each patient’s care planning.