TEWV trust told patient’s autism diagnosis had been ‘overlooked’

Jay Jones was found dead in his bedroom at the Roseberry Park Hospital in Middlesbrough, run by the Tees, Esk and Wear Valleys NHS Trust, on December 27, 2022.

Teesside Coroners’ Court heard on Tuesday (April 21) how an independent review into Jay’s care was requested by TEWV workers to determine what more could be done to help him.

A jury was told the TEWV commissioned an independent review of Jay’s care shortly before his death.

Dr Sagarika Nag said a multidisciplinary meeting concluded clinicians were struggling to find further ways to help him. Specialist Anna Hay carried out the review on December 15 and notes were recorded on December 21, days before he died.

The review examined whether Jay’s care plan was meeting his needs, and, the inquest was told, concluded his original diagnosis of autism may have been overlooked and masked by mental health issues.

But Dr Nag told the hearing she did not believe the diagnosis had been ignored, and the jury was told a plan had also been created to support Jay’s care, setting out his preferences and aversions to help staff better support him, as they attempted to navigate his autism and other diagnoses.

Despite that, the jury heard Jay posed a “chronic and constant” risk to himself through repeated instances of self-harm.

Dr Nashwa Dandash, a community consultant psychiatrist responsible for Jay when he was not in hospital, said there were major concerns about him being both in and out of the mental health unit. She explained that while he faced a significant risk of death due to his behaviour in the community, there were also fears his behaviour could escalate if he was admitted to hospital.

23-year-old trans man Jay Jones who died in his room at Roseberry Park, Middlesbrough (Image: FAMILY)

Emma Broughton, a mental health nurse, said records showed the risks Jay posed to himself increased during hospital admissions and because of this the admissions were often kept short.

Emma’s evidence also noted a significant escalation in the level of risk he posed to himself during the period leading up to his death.

The court then heard from Nicola Willis, a care coordinator and community psychiatric nurse with the Middlesbrough Effective Outreach Team, whose role included coordinating Jay’s care while he was in the community.

She said it was often difficult to maintain regular engagement with him, adding: “At times Jay would say that he did not wish to work with me and at other times he was happy to engage.”

Roseberry Park Hospital in Middlesbrough. (Image: NORTHERN ECHO)

Jay was born as Tia Hope Jones, in Northallerton in December 1999 and later moved to Middlesbrough at the start of Covid in 2020. The court heard he had hoped to train as a paramedic.

He had a long history of self-harm and suicide attempts and had been admitted to hospital 26 times in the 34 months before his death.

On the afternoon of December 27, 2022 staff saw him at around 3pm sitting on a sofa in a communal lounge speaking with others before he returned to his bedroom.

During a routine patrol at about 4pm he was found unresponsive in his room. Staff began CPR and an emergency response team arrived about ten minutes later and continued resuscitation efforts for around twenty minutes before he was pronounced dead.

A postmortem examination carried out at James Cook University Hospital found cocaine and other drugs in his system. The cause of death was recorded as a method commonly associated with suicide, with multiple other injuries consistent with self harm.

In a video tribute shown to jurors, his mother Donna Watson said he was one of six siblings and was always “fighting for attention”, but remembered him as the “funniest person” and a “ball of energy”.

She added that he was “so caring behind all his mental health problems”.

The inquest continues.