Man died after months without mental health care

James Southern had suffered from pain and anxiety since being involved in a motorcycle accident in 2002

A coroner has found NHS errors led to a man with a history of mental health issues being left without care in the months before he died from an accidental overdose.

James Southern, 41, died after being discharged from Highbury Hospital, a mental health facility in Nottingham.

An inquest heard Nottinghamshire Healthcare NHS Foundation Trust should have been allocated a care co-ordinator when he left the hospital, in September 2022, but this did not happen because of "errors in his records".

The trust has apologised to Mr Southern's family and said aspects of his care were "not of the standard" its patients deserved.

Assistant coroner Sarah Wood concluded the errors "misled" both medical staff, and Mr Southern, who was known as Jimmy, into thinking a care co-ordinator had been assigned.

In a prevention of future deaths report, Miss Wood said: "Jimmy's case was not transferred to another care co-ordinator when his care co-ordinator was absent.

"This meant Jimmy was left without care in the months leading up to his death."

Mr Southern was sectioned at Highbury Hospital and discharged in September 2022

Lawyers representing Mr Southern's family said he had no contact with a care co-ordinator between 18 November 2022 and 16 January 2023, and again between 6 February 2023 until his death on 31 May.

The inquest heard the father of three had suffered with pain and anxiety since he was injured in motorbike accident in 2002, and in order to cope, he was known to self-medicate.

The inquest heard he died after his father found him unresponsive at his home in Cotgrave, Nottinghamshire, in May 2023.

The coroner concluded he died after accidentally taking an overdose of a mixture of drugs.

Miss Wood said there was evidence Mr Southern's medical records were amended after death.

She has written to the trust stating she was concerned "there remain potential issues of poor record-keeping".

The coroner also highlighted her concern over the level of communication between trust staff, and with patients.

She has asked NHS bosses to outline what action they will take to prevent future deaths.

Disciplinary proceedings

Mr Southern's mother Norma Southern told the BBC: "There was no help for Jimmy when he came out of Highbury.

"We feel he was forgotten about. If there had been help he might still be alive today.

"It's such a shame that he is no longer with us and there for his kids.

"I thought the coroner was brilliant. I feel we finally have justice for Jimmy and I hope not family has to go through what we have."

Lawyer Greg Almond, who is representing the Southern family, said: "Jimmy's family are devastated by his passing, particularly as he leaves behind children and a grandchild, all of whom he loved and adored deeply, along with both of his parents, and a fiancée whom he was due to wed in December this year."

The trust's executive director of nursing Diane Hull said: "I once again offer our sincere condolences and apologies to James's family and friends for their loss.

"We recognise that there were aspects of the care delivered to James that were not of the standard our patients deserve and for that we are truly sorry.

"We are working to address the other issues raised by the coroner to improve the experience for patients now and in future.”

She said disciplinary proceedings had been launched against a clinician when the trust became aware Mr Southern's records were amended after his death.

The matter has also been referred to the Nursing and Midwifery Council (NMC) watchdog.

The NMC has been contacted for comment.

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