Company boss from Fair Oak died after NHS neglect, coroner says

On 24 August, a nurse breached a plan not to tell Doughty of his likely detention under the Mental Health Act.

“This was an unnecessary, ill thought-out and risky disclosure… and left him anxious and frightened,” the coroner concluded.

Nurse Moussirou, a bank nurse employed by an agency for Southern Health, then dismissed family concerns about the effect on him.

The two failures were a “gross absence of caregiving”, the coroner said.

Doughty was found injured on 26 August and died in hospital two days later.

In a Prevention of Future Deaths Report, Walker said the NHS trust’s failures together amounted to neglect.

He added the trust was “routinely unable to secure acute psychiatric beds for patients”.

The widow’s solicitor, Gus Silverman, said: “It is unforgiveable that someone as vulnerable as Jonny should have been denied the care and treatment he needed because the Trust didn’t have a bed for him.

“No-one thought to trigger the processes that should have resulted in a bed being sourced in a private mental health hospital.”

In a response to the coroner, the NHS trust said it had reduced the length of patient stays to free up beds.

It added: “Private beds were sourced over the weekend that Mr Doughty died; we are sorry that his needs were not escalated using this route as required.”

A trust director, Donna Greenwood, said: “Our thoughts remain with Jonny’s family and friends and we are very sorry for their loss.

“We have taken action to strengthen our bed management and escalation processes, enabling clinicians to raise concerns earlier and escalate them to director level at any time.”

In a statement, a Department of Health and Social Care spokesperson said: “Our deepest sympathies are with the loved ones of Jonny Doughty. His case is a tragedy, and we are determined to learn the lessons from it.

“We are delivering a cross-government Suicide Prevention Strategy for England aiming to reduce the number of lives lost to suicide as well as improving support for those who have self-harmed or are bereaved by suicide and we continue to explore where we can go further.”

The spokesperson added that the government was “driving forward” plans for 159 new NHS mental health facilities across England to “ensure that fewer people reach crisis point in the first place”.