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Investigation and inquest
On the 1st March 2022, I commenced an investigation into the death of Thomas Jayamaha. The investigation concluded at the end of the inquest on the 15th March 2023
The conclusion of the inquest was Suicide
Circumstances of the death
Tom took his own life on by taking Pentobarbital, that he had ordered from a website abroad. He had Autism Spectrum Disorder (ASD), and a long history of suicidal ideation, with previous self harm/suicide attempts. He was aged twenty three when he died.
Tom had long term mental health difficulties, and he was repeatedly referred to the Nottinghamshire Healthcare NHS Foundation Trust by his GP, with the GP asking for ongoing psychological support, as Tom was considered too great a risk for him to be seen by Primary Mental Health services.
He had a number of factors in his life that made him vulnerable to low mood and suicidal ideation, including his ASD diagnosis, a history of sexual abuse, difficulties in his family relationships, and that he was in a long term coercive and controlling relationship, that was not understood by Trust staff.
Tom was also unaware of the local mental health team treatment plan for him when he died, and reportedly felt that the Trust could not help him as referrals were repeatedly rejected by teams across the Trust.
Coroner’s concerns
1. Delayed progress of the Autism Strategy work across the Trust. I ask that the Nottingham and Nottinghamshire Integrated Care Board provide a joint response with the Trust to address this concern, as I accept progress with the Autism work will depend upon resources and the agreed Com-missioning of specific services
2. Insufficient progress with Complex case management
3. The Serious Incident Investigation process
I am not reassured that necessary actions to address these serious issues identified are in place.
Information checked against the published report and official responses