"Concerns" have been raised over the standard of care in a rehabilitation care home as a "gentle" teenager died after he was found unresponsive.
An inquest has found the standard of note keeping and records were "insufficient" in terms of caring for 17-year-old Joshua Hemmings before he died.
The much-loved teen, from Waterloo, was today described as "gentle and kind" as his mother, Lissa Hemmings led tributes to him in Gerard Majella Courthouse.
She said: "He never put a foot wrong and he was an absolute sunshine."
Expressing their concerns over the level of care their son was given on a psychological and physical level, the court heard from Josh's loving family as details of the final months of his life were read aloud today.
The court heard how Josh, an apprentice brick-layer who was starting off in the family business, was diagnosed with psychosis in 2019 after the family took him to A&E over concerns they had for him.
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Reading aloud evidence, Coroner's Assistant Liam Moss said Josh had attempted to take his own life on occasions before, but on September 16, 2019, he took a drug overdose.
It was believed Josh could have had intentions of trying to end his own life, but Area Coroner for Liverpool and Wirral, Anita Bhardwaj, said his intentions could not truly be known as "the state of his mind was impaired".
Josh was rushed to hospital after his mum called 999, but he suffered a cardiac arrest while with paramedics.
It was concluded by doctors that Josh's brain was possibly starved of oxygen for 12 minutes and because of this, he was later diagnosed with a Hypoxic brain injury.
Following this, Dr Ganesh Bavikatte said Josh had "minimal awareness", had issues with his mobility, lived with a number of complex issues and struggled to swallow.
During today's inquest, details were heard about the care Josh was given from Mersey Care in the run up to the overdose.
Josh's mum, Ms Hemmings, said that after her son was diagnosed with psychosis there were attempts to have him detained under the mental health act.
She said: "He was my son and only 16, I didn't want him to think we had let him down."
A community care plan was put in place where Josh received daily visits from practitioners to support him.
Dr Debbie Marsden, from Mersey Care, said: "There was a care plan put in place for his family to support him. He was supported in the community and that's when we first met him.
"I went out to see Josh and I met him in April  for an urgent review. He was clearly unwell and he was struggling to attribute his thoughts."
Helplines and support groups
The following are helplines and support networks for people to talk to, mostly listed on the NHS Choices website
- Samaritans (116 123) operates a 24-hour service available every day of the year. If you prefer to write down how you're feeling, or if you're worried about being overheard on the phone, you can email Samaritans at firstname.lastname@example.org.
- Childline (0800 1111) runs a helpline for children and young people in the UK. Calls are free and the number won't show up on your phone bill.
- PAPYRUS (0800 068 41 41) is an organisation supporting teenagers and young adults who are feeling suicidal.
- Mind (0300 123 3393) is a charity providing advice and support to empower anyone experiencing a mental health problem. They campaign to improve services, raise awareness and promote understanding.
- Students Against Depression is a website for students who are depressed, have a low mood or are having suicidal thoughts.
- Bullying UK is a website for both children and adults affected by bullying.
Amparo provides emotional and practical support for anyone who has been affected by a suicide. This includes dealing with police and coroners; helping with media enquiries; preparing for and attending an inquest and helping to access other, appropriate, local support services. Call 0330 088 9255 or visit www.amparo.org.uk for more details.
- Hub of Hope is the UK’s most comprehensive national mental health support database. Download the free app, visit hubofhope.co.uk or text HOPE to 85258 to find relevant services near you.
- Young Persons Advisory Service – Providing mental health and emotional wellbeing services for Liverpool’s children, young people and families. tel: 0151 707 1025 email: email@example.com
- Paul's Place – providing free counselling and group sessions to anyone living in Merseyside who has lost a family member or friend to suicide. Tel: 0151 226 0696 or email: firstname.lastname@example.org
The Martin Gallier Project – offering face to face support for individuals considering suicide and their families. Opening hours 9.30-16.30, 7 days a week. Tel: 0151 644 0294 email: email@example.com
Because of Josh's supportive and strong family network, care continued at home with a care plan and Josh's mental health began to see improvements.
Dr Marsden added: "It was clear to us he had excellent family support at home."
Sadly, his mental health deteriorated some months later and Ms Hemmings claimed she raised concerns on more than one occasion she thought her son was suicidal.
In May 2019, Josh had attempted to end his life with pharmaceutical drugs.
Ms Hemmings also pointed out that when offered therapy, which Josh enjoyed, the opportunity for more sessions was a nine-week wait.
After another occasion where Josh had ingested a potentially lethal amount of drugs, Ms Hemmings said she made pleas for Josh to be taken to hospital to be cared for in a professional setting.
When asked why this did not take place, Dr Marsden said: "I didn't think clinically it was appropriate to detain him under the mental health act at that time.
"It was not our clinical impression that Josh presented with active suicidal thoughts that needed to be in hospital to manage."
Following Josh's overdose in September 2019, Dr Bavikatte said Josh suffered "diffuse and extensive brain damage."
Josh spent the next six months in acute care for his complex needs, before he was moved on to Oak Vale Gardens, a rehabilitation care home for people with an acquired brain injury.
As Josh was transferred, concerns were raised in the inquest that crucial notes about his care needs and medication were not passed on.
Information about his change of GP, details about medication he may need, were also found not to be passed on.
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Part of Josh's care included sometimes performing suctions to relieve him of a build up of fluids and saliva, as he had issues with swallowing.
When questioned, Michelle Montrose, registered manager of Oakvale Gardens, was asked how often Josh was checked on and crucially, how often did nurses check if he needed to have such fluids suctioned.
The court heard how on May 6, 2020, Josh was suctioned five times. On May 7, once, and on May 8th, the day of his death, not at all.
Tragically, on May 8, 2020, Josh was found with "secretions at the mouth", not breathing and unresponsive. CPR was administered for Josh, but because he had a Do Not Resuscitate order, this stopped and he sadly died.
While this is not clear if the lack of suctioning contributed to Josh's death, Ms Bhardwaj said, the poor note taking about if Josh had been suctioned was "concerning".
Ms Montrose said nurse's notes indicated Josh was checked on every 15 minutes, but there were no notes regarding oral checks
Ms Bhardwaj said: "I have expressed a grave concern with the note taking that took place and the record keeping.
"I'm appreciative that the pandemic has caused a lot of pressure and for systems to change, and it was very, very difficult.
"But that does not take it away from the fact that the note keeping was very, very poor. Just to say observations have been checked out is insufficient and not at the standard you expect."
Ms Montrose replied: "I accept that".
She added since Josh's death, improvements about note keeping and retraining about records has also been carried out.
Recording a narrative conclusion, Ms Bhardwaj said Josh's cause of death was MDMA toxicity, Hypoxic brain injury and pneumonia.
She said: "Josh took his own life while the state of his mind was impaired."
Paying tribute to her son, Ms Hemmings said: "As a baby he was adorable and we were inseparable. We were so close.
"He never put a foot wrong and he was an absolute sunshine."
She added: "He went on to be a gentle, polite, loving and a very clever, vegan teenager. He loved his friends so much and they were his world."
Following Josh's death, a Just Giving page was set up for him where scores of people paid tribute to the young man.