9 February 2020

Following the inquest into the death of Luke Naish, his family issued the following full statement. 

See the media release for more information.

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. Throughout the inquest it was traumatising for us to read the vast amount of Luke’s medical notes and hear the various witnesses giving evidence. As a parent, to see how much Luke was asking for real help and to see no one taking any responsibility and instead blaming someone who was mentally ill, was incredibly distressing.

Avon and Wiltshire Mental Health Partnership NHS Trust had a duty to assist Luke with his care needs, taking into account his dual diagnosis. He needed support to access treatment around drug taking, yet was only ever signposted. We knew Luke needed supported living from the moment he was discharged.

I believe Luke's death was facilitated and enabled by the fact that the poor state of his mental health had not been fully appreciated, his care, treatment and supervision was withdrawn instead of increased with the obvious fact he was severely deteriorating. We feel Luke was blamed continuously by the trust for not engaging with staff and for taking drugs, and  the lack of information sharing was a significant contributor.

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. All I’ve heard throughout the inquest was that it was Luke’s fault for not engaging with staff, when it was obvious he was unable to live independently. I believe the findings of no lessons learnt was absolutely absurd and as you can imagine completely soul destroying!

Our mental health services are failing so many people by not delivering the correct care and support to its service users. It is quite obvious poor Luke had no chance. Our Mental health services are supposed to provide a safety net. But there are so many people out there who haven't had the support from their families like Luke did, and are severely suffering. If coroners and mental health services are not prepared to listen to families in inquests, then how can our very broken systems change?  The fact that they not trying to learn from this is utterly disgusting.

We would like say we are extremely grateful to the A&E staff in Weston general hospital who tried to help Luke on the 25th September, until he was handed over to the crisis team.  And to the people who found Luke in the woods and the quick response of our emergency services, they gave us 3 whole days to be with Luke and say our goodbyes. The staff in the intensive care at Southmead hospital were amazing, they gave us so much support and kindness. We found out that Luke had chosen to be an organ donor, his kindness and innocence never ceased, which is why we feel he suffered so much. This took that heart wrenching decision away from us. He has managed to save 3 lives and we feel honoured that his legacy lives on.

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.

He was my beautiful boy and our so very special Superluke!”