16 May 2019                                         

Before HM Senior Coroner Tony Williams
Taunton Coroners Court

Tuesday 14 May – Wednesday 15 May 2019

The inquest into the self-inflicted death of Reece Baker concluded on 15 May, with the Coroner at Taunton Coroners Court returning a conclusion of suicide. Reece was 23 years old when he died on 9 October 2016. He was not consistently under the care of a community mental health team and had been considered more appropriate for treatment by drug and alcohol services.

The inquest heard that, due to a change in policy by Somerset Partnership NHS Foundation Trust after his death, Reece would now have been considered appropriate to receive services from the Dual Diagnosis Team.

Reece was from Bridgwater in Taunton. His family described him as the life and soul of many an occasion. They said Reece would put a smile where a tear had flowed and force a laugh from someone in mid temper. In the months prior to his death, Reece had made multiple suicide attempts. There were significant challenges in his life at this time, including the breakdown of his relationship, loss of his job and accommodation. He also experienced issues with alcohol use.

Reece took his first overdose in December 2015. He was admitted to Musgrove Park Hospital for treatment for the resulting liver damage. Upon being medically fit for discharge he was assessed by the Psychiatric Liaison Team at Somerset Partnership NHS Foundation Trust on the first of numerous occasions. It was decided that his needs would best be met by drug and alcohol services.

At this time, Reece also made a self-referral to Somerset Talking Therapies. The inquest heard evidence that Reece waited over 22 weeks for his first counselling appointment.  He then missed this appointment because he was in hospital following his fourth suicide attempt and was discharged from the service.

The central concern for the family is that Reece also exhibited signs of depression, anxiety and suicidal ideation when not under the influence of alcohol. At the time he was not deemed to fall under the Trust’s Dual Diagnosis Policy. During the inquest evidence was heard that the practice around Dual Diagnosis has been reassessed and were Reece presenting with the same symptoms today, he would be seen by the new Dual Diagnosis Team. It was of note that following his death the toxicology results showed that Reece had not consumed excessive alcohol before his self-inflicted death.  

Alan Baker, Reece’s father said:Throughout this most dreadful time we have carried the weight of sudden loss, grief, guilt and anger. Reece was a loving father, son, brother and friend to many and his life fell apart with many witnessing his fall not knowing how to support him. Reece was never officially diagnosed with a mental health condition. Medical professionals formed the view that he had an alcohol dependence problem. Much to his and our family’s frustration they repeatedly told him that he had to address his alcohol issues before they could offer him support with his mental health. We were pleased to hear of the changes that have been made to the Dual Diagnosis policy and sincerely hope that this will save other young men in Reece’s position.”

Fleur Hallett of MW Solicitors who represented the family said: “It was extremely concerning to learn of the waiting times involved in the provision of care to a vulnerable young man. Reece waited 22 weeks for a counselling appointment, he was told he would wait four to six weeks for a psychiatric review in the community, which never took place and we learnt that there are substantial waiting times to be allocated a care co-ordinator.”

Remy Mohamed, Caseworker at INQUEST, said: “INQUEST is increasingly contacted in relation to deaths of people with multiple needs who are falling through the gaps between services. It is desperately sad that only after Reece’s death was there a policy change that may have given Reece access to the help he so clearly needed. Widespread action and learning across NHS Trusts is needed to ensure the same failures for people with dual diagnoses are no longer repeated nationally.”



For more information contact Lucy McKay on [email protected] or 020 7263 1111.

INQUEST has worked with the family of Reece Baker since April 2018. The family is represented by INQUEST Lawyers Group members Fleur Hallett of MW Solicitors.

Other Interested Persons represented at the inquest were Somerset Partnership NHS Foundation Trust.

On 31 January 2019, the inquest into the death of Timothy McComb concluded. The conclusion by the coroner was also suicide. Timothy had multiple needs around mental ill health, substance addiction, and a learning disability.