9 February 2021

The family of Luke Naish are hoping to challenge the uncritical inquest into his death, launching a CrowdJustice fundraiser and campaign page ‘Voice for Luke’. The inquest, concluding on 23 January, identified no failures or points of learning for those tasked with Luke’s care, despite a range of critical evidence. The family remain 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 2 October 2018, three days after he was found hanging. 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.

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 HM Coroner Dr Peter Harrowing at Avon Coroner’s Court from 18 to 23 January 2021. A range of critical 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. Yet the coroner’s conclusion highlighted no failures in care or issues with the Trust, and identified no points of learning to prevent future deaths.

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


Luke was a bright, funny and happy child, absolutely adored by all the family who called him ‘our SuperLuke’. His family describe him as a kind, loving soul with a great sense of humour, who appreciated any help and was always polite and courteous. Luke experienced mental ill health from a young age, after becoming reliant on cannabis and experiencing paranoia, and later psychosis. Luke initially had positive experiences with mental healthcare and rehabilitative treatment for addictions. However, after experiencing a violent attack, his mental health worsened and he had a period of homelessness.

Luke’s family worked hard to support him, and eventually in 2016 he was offered a flat in Weston Super Mare. However, it became clear Luke was unable to live independently. His family were hopeful about plans to assess him for supported living. In early 2017 Luke registered with Coast, who provide adult community mental health services as part of Avon and Wiltshire Mental Health Partnership NHS Trust, and was given a care co-ordinator. Despite the help from his family, Luke received little more support from local services, leaving him lonely and struggling to look after himself in a barely furnished flat.

His mental health went into serious decline. He was sectioned for treatment from November to December 2017. Only after his death, his mother learned Luke had attempted suicide weeks before discharge. Luke was discharged into the care of the Community Mental Health Team where he should have been provided continued care (under section 117 of the Mental Health Act 1983). However, a care package was not put in place until two months later when Manor Care were allocated to provide support in February 2018.

Despite earlier discussions, Luke had still not been assessed for supported living and was back in his flat receiving 14 hours of care a week. However, at a promising meeting in May 2018 Luke and his family were led to believe there was a place for him in supported living in Bristol. They were relieved and Luke was hopeful and excited about this prospect. Sadly, the place never materialised.

Luke lost hope and his mental health continued to decline. He began to take a large number of drugs and often went missing. Luke’s family had become increasingly concerned, finding he was living in squalid and dangerous conditions, but with minimal response from those tasked with his care. The family raised concerns that the care plan in place was not meeting Luke's needs, however no change was made. In May 2018, Manor Care themselves informed Luke's care coordinator that the plan was not suitable, however still nothing changed.

Avon and Wiltshire Mental Health Partnership NHS Trust made the decision that Luke must address his addiction's alone before support could be provided, despite his mental health conditions being precipitated by those very addictions. In August, having warned in May that the care package was not working, Manor Care communicated they would no longer provide care due to Luke’s drug use. At the end of their notice period Luke was to be left with no care package in place again.

In late August 2018, Luke removed family members from his Next of Kin list and nobody else was added, leaving no point of contact for support. Throughout August and September 2018, Luke expressed suicidal thoughts to a number of individuals and agencies, but no family members were made aware of this.

On 25 September 2018, Luke again told his care coordinator and their colleague that he felt suicidal and needed to be sectioned. Luke informed the care coordinator that he had a detailed plan to complete suicide, and had already been to the location with a ligature. His care coordinator told him that if he felt overwhelmed he should dial 999, and left Luke alone in his flat. The notes of that meeting stated that there were no serious concerns about Luke's presentation.

Later that day, Luke called an ambulance and was taken to Weston General A&E.  He was assessed by triage nurses and a Doctor, who told him not to go back to his flat or be alone. The Crisis Team were called. Luke again told them he felt he could not keep himself safe and he needed to be sectioned. He expressed his intent to hang himself if this did not happen. However, the crisis team felt he was just looking for a bed for the night and that his mood had lifted, so they sent him home alone. No one checked on him, or informed his family.  Luke was found hanging on 29 September and died in hospital three days later on 2 October 2018.


After previous inquest hearings in October 2019, September 2020, and a three day hearing in January, the inquest concluded that Luke “hung himself with a ligature on 29 September 2018. This act caused his death. At the time he took this action he was probably suffering from an episode of psychosis of unknown origin”. The coroner found no causative link between the family's concerns and Luke's death, and found there were no failures on behalf of Avon and Wiltshire Mental Health Partnership NHS Trust. Luke's family feel that the Coroner's conclusion does not reflect the extensive evidence heard throughout the inquest.

For example, during the inquest a psychiatrist who had treated Luke previously accepted, on the basis of what was known by Avon and Wiltshire Mental Health Partnership NHS Trust, that "it called out for admission" when Luke attended A&E on 25 September 2018. However, the Coroner did not accept this evidence on the basis that the psychiatrist had not seen Luke that day.

Evidence was also heard that the appropriate managers and supervisors were not aware of Luke's deteriorating presentation, despite the fact that he was constantly deteriorating. However, the Coroner found no failures in relation to management and supervision within the recovery team.

It was also highlighted in the inquest evidence that the practitioner supervising Luke's care coordinator felt that a formal capacity assessment should have been conducted and recorded in relation to Luke's capacity to remove his family from his Next of Kin list.

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, his conclusion was that there were no failures at all within Luke's care. He also declined to make a Report to Prevent Future Deaths on points of learning. As a result, the family are seeking legal advice to challenge the Coroner's conclusion.   

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.”

See the full family statement here.

Craig Court and Holly Spencer-Biggs of Harding Evans Solicitors, who represent the family said: "The evidence heard made clear that the care Luke received was inadequate including, but not limited to, serious staff shortages leaving staff with unmanageable workloads, ineffective management systems and lack of staff absence procedures.

This inquest enabled public scrutiny of the facts of Luke's death and the internal failures of Avon and Wiltshire Mental Health Partnership NHS Trust in providing Luke with the appropriate care that he needed. We are very disappointed with the conclusion given by the Coroner, in light of the significant evidence that had been heard, and are considering it carefully with the family with a view to possibly seeking a Judicial Review of the same."

Selen Cavcav, Senior Caseworker at INQUEST, said: “Luke’s family were relentless in their fight to get appropriate care and treatment for him. Nobody should have to fight for this, but sadly people with dual diagnosis too often struggle to access joint up support. Both Luke and his family were failed by a stretched and disjointed community mental health system, and an inappropriate crisis response. They have been failed again by this inquest.

The issues Luke experienced are systemic across mental health services, and must be addressed now more than ever. To save lives we need an accountable system which identifies and addresses issues in care. We stand with Luke’s family in their ongoing pursuit of justice for Luke and all those affected by failing mental health services.”


For further information, interview requests and to note your interest, please contact Lucy McKay on [email protected] or 020 7263 1111. A picture of Luke is available here.

For more information see:

Luke’s family are represented by INQUEST Lawyers Group members Craig Court and Holly Spencer-Biggs of Harding Evans Solicitors. Counsel for the family is David Hughes of 30 Park Place.

Other Interested persons represented are Avon and Wiltshire Mental Health Partnership NHS Trust and another individual IP.

Evidence at this inquest was previously heard in October 2019 and 15 September 2020.


Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.