Company boss died after NHS neglect, coroner says

A psychiatric patient was frightened into taking his own life when a nurse suggested he might be detained against his will, a coroner has said.

Jonny Doughty, 42, was found fatally injured at his home in Fair Oak, Hampshire, in August 2024.

The company boss should have been given a hospital bed by Southern Health NHS Trust, coroner Nicholas Walker said.

The trust's director of quality and professions said it fully accepted the coroner's findings and concerns, adding that it had "taken action to strengthen our bed management and escalation processes".

Doughty's widow said her "loving and loyal husband... was let down at a time when he most needed support".

Sarah Doughty said: "Before he got ill, Jonny was the most wonderful person.

"He loved our children immensely and I know it was his greatest joy to be their dad.

"Jonny and I grew up together. We walked through every season of life confident that we could get through anything because we were by each other's side."

The air conditioning firm boss suffered a decline in his mental health in 2024, the inquest heard.

However, Southern Health failed to arrange a prompt outpatient appointment and left him at home because of a lack of hospital beds, the coroner said.

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".

In a response to the coroner, Hampshire and Isle of Wight Healthcare NHS Trust, which has taken over from Southern Health, 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."

His 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."

Donna Greenwood, director of quality and professions at the Hampshire and Isle of Wight trust, said: "Our thoughts remain with Jonny's family and friends and we are very sorry for their loss.

"We fully accept the coroner's findings and the concerns raised in the Prevention of Future Deaths report.

"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."

She said it was also continuing to improve bed availability and developing greater support for people experiencing a mental health crisis in the community.

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."

They 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".