Exclusive:Medical practitioners 'could not have prevented' Portsmouth uni student's death, coroner concludes

Medical practitioners “could not have prevented” a university student from taking his own life, a coroner has ruled.

Joshua Warner died on January 31, 2023, at Rosalind Franklin Halls in Guildhall Walk, Portsmouth. The 21-year-old, who had been studying psychology, purchased poison online from Kenneth Law, 57, from Mississauga, Canada, who has since pleaded guilty to aiding suicide.

This week, an inquest into his death has been held at Winchester Coroner’s Court, where evidence has been heard from mental health professionals involved in Joshua’s treatment, including staff at Uni-City Medical Practice in Portsmouth, and his private therapist, Dr Kevin Scott.

All of them were told by Joshua that he was starting to feel better and that his newly-prescribed medication was working - just days before his death.

Concluding the inquest, coroner Nicholas Walker said: “Joshua was, and is, so much more than the conversations we have been having. Unique, quirky, fiercely loyal, a dry sense of humour and quick wit. His family describe him as being a deep thinker, and introspective.

“Sadly, you say, he was to trapped in his own thoughts. He was able to deceive people of those inner thoughts that were eroding his mental health. I am satisfied that he intended to take his own life.

“It seems to me that the heart of this case is whether the professionals should have seen through Joshua’s deception - he was apparently getting better.

“I am satisfied, on the balance of evidence, that Joshua’s death cout not have been predicted or prevented. He was saying that he was feeling better; he was an intelligent young man, and even those who knew him best did not see his coming.”

Mr Walker added that Joshua and his family were “frustrated” by his treatment in the primary care sector. Over the Christmas period of 2022, his father, Dr Graham Warner, wrote an email to the chief medical officer of what was Solent NHS Trust - and only through that was his son assessed.

“It should not be down to the dogged perseverance of a concerned father to get he help that was needed,” Mr Walker said. “I’m quite satisfied that he would not have had a consultation, had it not been for his dad. It should not have taken that.”

Following a toxicology report, Joshua’s medical cause of death was recorded as intoxication from a highly toxic substance.

While the substance was specifically named in court, The News has chosen to omit this from publication, based on guidance from Samaritans on reporting suicide - as well as at the recommendation of the coroner.

The court heard how the substance is available in the UK, but is not sold to individuals.

Over the course of the inquest, evidence was heard of how NHS trusts, the GP surgery and the University of Portsmouth had found “areas of learning” in the aftermath of Joshua’s death, and had made improvements since - although not all of these were intrinsically linked to his passing.

Mr Walker recorded a conclusion of suicide, summarising that Joshua Warner, known also as Jeremy, intended to take his own life.

If you've been affected and bereaved by suicide, Cruse is a dedicated service providing free and confidential support across Portsmouth, Southampton, Hampshire and the Isle of Wight. Call 0330 555 0129, or visit supportaftersuicideship.org.uk

If you need urgent help with your mental health, there is free support available 24/7 from:

Samaritans - call 116 123

Shout - text HANTS to 85258

NHS - call 111 and select the mental health option, or in an emergency, call 999