John Taylor PartridgeAn assistant coroner has said he will write to Health Secretary Jeremy Hunt about gaps in the law and in definitive protocol about whether 16 and 17-year-olds with mental ill health should be treated under the Children’s Act or the Mental Capacity Act. 

The assistant coroner for Cornwall, Plymouth & Devon, Mr Andrew Cox, made this call after delivering a conclusion of suicide at Plymouth Coroner’s Court in the case of John Taylor Partridge, 17, who was admitted to hospital after taking an overdose but was later assessed as being ‘low risk’ and discharged – only to take his own life a day later.

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

John’s mother, Sandy Partridge, also called for change: “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 and having self-harmed.

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 child and adolescent mental health services (CAMHS) in Plymouth 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 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, could self-discharge and 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, but 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. But the following day, John took his own life.

Sandy – via a statement from her legal team – said: “John should never have been discharged – we believe his death was avoidable.

“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 7-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.”

In his findings, Cox 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 e.g. 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.

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