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The Lancashire Telegraph
July 22, 2021
The proceedings on Wednesday July 21 heard that Jonathan Stones, from Darwen, took his own life on February 8, 2020, during Storm Ciara after having struggled with mental health problems as well as alcohol and drug use.
Coroner Dr James Adeley also ruled that, though they would not have made a difference in this case, errors were made by health services in communication and around discharging that “in other cases could have catastrophic consequences.”
Turning to the communication and discharging issues, he added: “The other issues I’ve addressed, I want the trust to look at because I don’t want them happening again.”
The proceedings, held at Accrington Town Hall, heard from witnesses including Lancashire and South Cumbria NHS Trust mental health nurse and crisis home team leader, Sasha Fort, consultant psychiatrist Dr Moruf Adelekan and service manager for specialist mental health services Lynn Charnley.
Ms Fort explained that Mr Stones began receiving care in the community from November 25, 2019, after a friend raised concerns about his mental health, include symptoms of paranoia and suicidal thoughts, along with substance misuse problems including cannabis and alcohol.
He was initially put on a red alert and seen by the home treatment team on November 26, after which he was prescribed anti-depressants.
Ms Fort said: “It was felt that he could be managed within the community by the home treatment team.”
A care plan was agreed for Mr Stones and he was due to be seen on January 10 and he was due to see Inspire Blackburn, which supports people with drug and alcohol problems.
However, his problems recurred and he appeared at Royal Blackburn Hospital A&E on January 9 and was taken to Ribble Ward, a secure mental health facility
Ms Fort said: “On reading the report there are areas we could improve on including communication and joint working with Inspire.”
However, Mr Stones was not sectioned with Dr Adeley explaining that in cases like this the patients loss of agency can do more harm than good, meaning that he could not be detained if he wanted to leave.
Dr Adelekan said: “He was quite cooperative, he admitted that drugs were his problem but he wanted to turn the bend.
“He wanted to meet Inspire the next week so that was quite reassuring.”
However, against medical advice, Mr Stones decided to spend the weekend with his ex-girlfriend Julie Lightbown, after which he decided not to return to the ward and was discharged.
After the discharge he appeared to have stabilised and accessed Inspire Blackburn on January 17, 2020.
However it was not clear to the Inspire team, whether or not Mr Stones had been discharged by the home treatment team.
Dr Adeley said that there should have been a discharge meeting, but that this did not happen.
Speaking about the problems the agencies had faced, Ms Charnley said: “The common denominator is communication between all services.”
Mr Stones’ sister Helen Westwater, who he had stayed with in Leyland, told the inquest that she was in daily contact with him.
He appeared to be planning for the future and was working on a house he hoped to redevelop.
Ms Westwater said: “Before taking drugs he was amazing, he was bubbly, outgoing, he was the life and soul of the party, he had so many friends.”
However, after having spoken to him on the phone on Friday February 7 while he was staying at another friend’s house, Ms Westwater arrived the next day to find he was not there.
Following a search, Mr Stones was found dead by police on February 9, with PC Matthew St Pierre telling the inquest that there were no signs he had been assaulted.
As such, Dr Adeley ruled that Mr Stones’ death was caused by suicide and that he had died on February 8.