Mental health care failures contributed to Hampshire father’s death, coroner finds

Serious failures in NHS mental health care contributed to the death of a Hampshire father-of-two who had been experiencing psychosis and suicidal thoughts, a coroner has concluded.

Jonathan “Jonny” Doughty, 42, who ran an air-conditioning business, was found critically injured at his home in Fair Oak in August 2024. He died at Southampton General Hospital two days later.

Mr Doughty had been considered for assessment under the Mental Health Act after refusing treatment, harming himself and showing signs of significant deterioration. However, the assessment was placed on hold because an inpatient psychiatric bed could not immediately be found.

Clinicians had decided not to tell him about the proposed assessment because of the risk this information could create. Despite this, a crisis-team nurse repeatedly told him that he could be detained, leaving him frightened and increasingly distressed. The nurse also failed to escalate the search for a bed as his condition worsened.

Coroner Nicholas Walker concluded that several failings had contributed to Mr Doughty’s death and that, taken together, some amounted to neglect. He issued a Prevention of Future Deaths report raising concerns about the availability of psychiatric beds and the process for obtaining alternative placements.

Hampshire and Isle of Wight Healthcare NHS Foundation Trust, which has since taken over the relevant services from Southern Health, accepted the coroner’s findings. It said work had been undertaken to reduce inpatient stays and improve access to beds, but acknowledged that Mr Doughty’s case had not been escalated through the correct process.

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