15 January 2021

Before HM Coroner Dr. Peter Harrowing
Avon Coroner’s Court (Remote access only)
Resumes 18 January 2021, 10am - scheduled for five days
(Evidence previously heard in October 2019 and September 2020)
Luke Naish, 28, died in hospital on 2 October 2018, three days after he was found hanging. Luke had a dual diagnosis of psychosis and substance misuse and was under the care of community mental health services in Bristol. Two days prior to Luke being found hanging, he had attended A&E requesting support and expressing that he had suicidal intent. However, his request to be admitted to hospital was refused. The inquest into his death resumes on Monday 18 January.
Luke was a bright, funny and happy child, absolutely adored by all the family. He was a kind loving soul and had a great sense of humour. He appreciated any help and was always polite and courteous. Luke's lovingness and selfless manner was illustrated through his affection towards animals and great affection with the family’s pets.
Luke had a complex history of mental ill health. He had been sectioned for treatment from November to December 2017. He 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 after he was discharged in February 2018 and during this time Luke's mental deteriorated further.  
In the months before his death, Luke’s family had become increasingly concerned about his deteriorating mental health, finding he was living in squalid and dangerous conditions. They repeatedly contacted the mental health team to get additional support to no avail. On 25 September 2018, Luke told his care coordinator and a colleague that he felt suicidal and needed to be sectioned. His care coordinator told him that if he felt overwhelmed, he should dial 999. Later that day, Luke called an ambulance and was taken to Weston General A&E. However, the crisis team did not admit him and sent him home alone.
Luke’s family hope the inquest will explore any shortcomings in his treatment by mental health services, including whether the care provided was adequate, whether Luke should have been admitted as an inpatient, and whether there was a failure to adequately review Luke’s care and treatment plans.



For further information, interview requests and to note your interest, please contact INQUEST Communications Team on 020 7263 1111 or [email protected] [email protected]
Journalists wishing to follow the hearings should contact Avon Coroner’s Court to request remote audio access. Due to the current circumstances, in person attendance is strictly limited and journalists should only attend remotely.
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.
Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.