Jonathan Doughty

On 06 September 2024 I commenced an investigation into the death of Jonathan Edward DOUGHTY aged 43. The investigation concluded at the end of the inquest on 24 April 2026. I concluded the inquest identifying a number of failings that possibly and probably contributed to the death of the deceased, some of which, in combination, amounted to neglect.

Jonathan Edward Doughty died in Southampton General Hospital on 28th August 2024, two days after he was found hanging at his home in Eastleigh, Hampshire. He died as a consequence of the hanging. The deceased’s mental state significantly deteriorated during 2024 and on 23rd August 2024 it was considered that he should be assessed under the Mental Health Act 1983 with a view to an involuntary admission to a psychiatric hospital because he was refusing treatment and medication, harming himself, was actively suicidal and showing signs of psychosis. The assessment could not take place as an acute bed was not available and he had to be kept safe in the community until a bed was found.    

The medical professionals who ordered the assessment were concerned that if the deceased knew of the plan to assess him, and its likely consequences, he would be at risk of harming himself and so planned for him not to be told about it for his own protection.  Over the next two days, a nurse from the mental health crisis team visited the deceased and told him in robust terms of the plan to assess him under the Mental Health Act. I found that the deceased was greatly affected by this unnecessary and risky disclosure and was made frightened and anxious by it, and that it more than minimally contributed to the deceased taking his life the day following the visit by the crisis team nurse.

In my opinion unless action is taken to address the above concerns then there is a significant risk of future deaths and I believe each of you have the power to take such action.