Tributes have poured in for a “kind and intelligent” teenager who tragically died last year.
Yesterday, a coroner said she had “grave concerns” over the care Joshua Hemmings received in the days before his death.
An inquest held for the 17-year-old heard note taking in the days before his death was “not at the standard you’d expect” and there were multiple occasions where his mum pleaded for more care for his mental health.
Josh, from Waterloo, sadly died on May 8 last year while he was being cared for in Oak Vale Gardens, a rehabilitation care home for people with an acquired brain injury.
The apprentice brick layer was living with a brain injury and complex health issues after he had taken a drug overdose in September 2019.
Recording a narrative conclusion, Area Coroner for Liverpool and Wirral Anita 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.”
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As well as hearing about the standard of psychological and physical care Josh received in 2019 and 2020, yesterday’s inquest also heard a touching tribute from his mum, Lissa Hemmings.
Ms Hemmings said her son was a talented rapper, loved his friends and was very intelligent.
In a statement read aloud to the court, Ms Hemmings said: “As a baby he was adorable and from then on we were inseparable, we were so close.
“He never put a foot wrong and he was an absolute ray of sunshine.”
As Josh grew, Ms Hemmings said: “He adored animals and he had such a kind heart.”
She said the pair would pick flowers together in the park when Josh was a little boy and the two of them loved spending time with each other.
She added: “He was gentle, he was just Josh.”
As Josh got older, Ms Hemmings said he considered becoming a brick layer, like his dad, or a labourer but he wanted to go into the family business.
Ms Hemmings said: “He went on to be a gentle, polite, loving and very clever vegan teenager.
“He loved his friends so much and they were his world.”
Scores of ECHO readers also paid tribute to Josh yesterday, and offered their condolences to his family.
Steven Shanley said: “That’s heartbreaking, the poor boy, so young. May he always RIP. Condolences to his heartbroken family and friends.”
Hailey Parkinson said: “Absolutely heartbreaking, thinking of the family and friends right now. Hugs to his mum and dad love from us all xxx”
And Glynis Parker said: “Heart breaking my deepest sympathy for his mother, family and friends. I wish mental health was better cared for in the country.”
Another ECHO reader also commented on the report, saying: “I only heard about this a few months ago and was horrified to hear this.
“Send all our love to the Hemmings family, from your old neighbours Seaforth.”
Mental health and suicide support
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
Following Josh’s overdose in September 2019, Dr Ganesh 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.
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, and details about medication he may need, were also found not to be passed on.
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.
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While it 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.
Following Josh’s death, a Just Giving page was set up for him where scores of people paid tribute to the young man.