The family of a Weston man who took his own life are challenging the inquest findings into his death

Luke Naish’s family is hoping to challenge the uncritical inquest into his death by applying to the High Court for a judicial review.

Luke's family has a launched a CrowdJustice fundraiser and campaign page on Facebook called Voice for Luke which has so far raised more than £1,000.

The inquest, which concluded on January 23, identified no failures or points of learning for those tasked with Luke’s care.

The family remains concerned about the care Luke received for dual diagnosis of mental ill health and addictions, as well as unaddressed supported living needs.

Luke was 28 years old when he died in hospital on October 2, 2018, three days after he was found hanging in Worlebury Woods.

Luke had both psychosis and substance misuse issues and was under the care of community mental health services in Bristol, part of Avon and Wiltshire Mental Health Partnership NHS Trust (AWP).

In August 2018, Luke's care provider Manor Care gave notice that they were no longer able to continue providing for Luke due to his drug use. They were to continue providing the care during the notice period but no steps were taken to provide Luke with further or alternative support by his care co-ordinator.

The care plan that both Manor Care and the family had identified as inadequate was not updated.

Two days prior to being found, Luke had attended A&E requesting support and expressing that he had suicidal intent. However, his request to be admitted to hospital was refused.

The final hearing of the inquest into Luke’s death took place before coroner Dr Peter Harrowing at Avon Coroner’s Court.

A range of evidence was heard around the need to admit Luke prior to his death, a lack of awareness of Luke’s deteriorating condition from those managing his care, and questions around Luke’s capacity when he was able to remove everyone from his next of kin list.

However, the coroner’s conclusion highlighted no failures in care or issues with the trust and identified no points of learning to prevent future deaths.

The coroner found no causative link between the family's concerns and Luke's death, and found there were no failures on behalf of AWP, although the coroner did acknowledge that there were issues in relation to staffing levels, staff being overworked and the required risk assessments and care plans not being updated.

Luke's family feels that the coroner's conclusion does not reflect the extensive evidence heard throughout the inquest.

As a result, the family is seeking legal advice to challenge the coroner's decision and is seeking support from individuals and campaigners in helping them to access justice.

Sarah Burrows, Luke’s mother, said: “My beautiful boy has now gone forever and is dearly missed by all who knew and loved him. As a family we never stopped fighting the mental health system to get him the support he needed and are devastated by the outcome of the inquest.

“Avon and Wiltshire Mental Health Partnership NHS Trust had a duty to assist Luke with his care needs, taking into account his dual diagnosis.

“Over the past two years we have been working hard to highlight failures by the trust and invoke change during Luke’s inquest. However, it has fallen on deaf ears.

“Our mental health services are failing so many people by not delivering the correct care. If coroners and mental health services are not prepared to listen to families in inquests, then how can our very broken systems change?

“Luke’s death was a totally unacceptable loss of life that could have easily have been prevented. So as well seeking advice for a judicial review of the coroner's decision, we want Luke’s voice to be heard far and wide to bring about change to our broken mental health services and help as many people as possible who are suffering out there.”