A family is facing the new year without their loved one but now has answers about how he died of an overdose while detained under the Mental Health Act.

Parents Peter and Julie Reid, both doctors, learned their 20-year-old son Jonathan, a former King’s School pupil, was given too much anti-psychotic medication when he was allowed home on weekend leave as part of the recovery process.

The couple, from Cinder Lane, Guilden Sutton, Chester, attended their son’s jury inquest which heard he was discovered drowned in the bath by a housemate at his Sheffield student flat on November 24 last year after taking an overdose.

Jurors concluded medical assessments and treatment were inadequate and “neglect” was a contributory factor in Jonathan’s death.

His parents Dr Peter Reid, a consultant cardiologist at the Countess of Chester Hospital, and Dr Julie Reid, a GP at the St Werburgh's Medical Practice for the homeless in Chester, agree there were deficiencies in their son’s care but “are not angry nor bear ill-will towards those who cared for Jonathan”.

Dr Reid, speaking on behalf of the family, expressed relief afterwards the jury was not allowed to consider a verdict of suicide.

He told The Chronicle: “Nine witnesses – including two psychiatric nurses, two psychiatrists, his occupational therapist and three flatmates – testified that he was not suicidal.  He was making plans for the future and was very happy to go out on weekend leave.

“We feel that the inquest was very well conducted and was a thorough examination of the circumstances of Jonathan’s death. This followed the previous detailed and thorough serious incident investigation performed by the Sheffield Health and Social Care Trust.

“We have not been left with any unanswered questions about his care. There has been an openness about the deficiencies in his care, not least an acknowledgement that the issuing of too much medication for his weekend leave was a serious error.

“After the conclusion of the inquest I was able to speak to the nurse who dispensed the wrong amount of medication and told him that we do not bear any ill-will towards him.”

‘Serious error’ made giving drugs to student

At the time of his death, 20-year-old student Jonathan Reid was under the care of the NHS having been sectioned after police found him wandering on a busy dual carriageway in Sheffield, an inquest heard.

The former King’s School pupil was recovering from his first psychotic episode which doctors said could have been triggered by drug use – he admitted taking cannabis recreationally for up to two years and two LSD tablets in the days before his admission – with course-related stress another possible factor.

Jonathan’s Sheffield GP Dr Mary Wren recalled his mental state shortly before he was sectioned: “I made a diagnosis of grandiose delusions. I asked about any thoughts of harming himself and he denied any such thoughts. His real concern was about protecting others, the vulnerable especially, and that was his intention in changing the world.

“He agreed to an assessment and wanted anti-psychotics to prove he was right, implying they would not work.”

The inquest jury heard Jonathan, a second year engineering student at the University of Sheffield, was later detained at Sheffield Health and Social Care NHS Trust for his own safety.

But the jury found that when granted weekend leave, as part of the recovery process, he was given a discharge dose of 14 Olanzapine anti-psychotic tablets instead of just three.

The jury also concluded there was “poor communication”, with evidence Jonathan’s housemates were not briefed when he went home. It also cited poor record keeping, inaccurate risk assessments and a lack of clinical leadership.

Consultant psychiatrist Dr Hassan Daudjee, who prescribed Jonathan’s medication,  accepted the fact his patient was accidentally handed his discharge dose by a nurse was “a serious error”.

“It was a mistake to give him 14 days supply,” Dr Daudjee told the inquest, explaining that the dispensing hospital was elsewhere. In the past he had prescribed the discharge dose in advance, which was kept in the same cabinet but a different folder, to avoid delays and frustration for patients come discharge day, but this practice had now ceased.

“You learn by your mistakes,” said Dr Daudjee, who diagnosed Jonathan as having suffered a hypomanic episode but felt he had been on the road to recovery.

Asked why he thought Jonathan had taken an overdose, Dr Daudjee said he had no answers. Recalling his last meeting with Jonathan, two days before his death, he said: “We had a good conversation. We had a laugh and a joke. He was bright.”

The psychiatrist added: “He said to the doctors, the medics and the staff nurses he would never take his own life, so...”

Dr Peter Reid
Dr Peter Reid

Jonathan’s father Dr Peter Reid, who was allowed to question the witnesses, referred several times to an investigation carried out by the trust.

He wanted to know about gaps in the medical records, a comment in the report which he interpreted as the trust’s failure to engage with family and friends over Jonathan’s treatment and the omission of a physical examination and brain scan.

Dr Reid appeared concerned that Jonathan’s housemates were not briefed when his son went back on weekend leave.

Dr Reid asked Dr Daudjee: “How important do you think it was the flatmates should have been contacted?”

The psychiatrist responded: “It would have been helpful, certainly, if they had been contacted.”

‘Our beloved son was so full of life’

Jonathan Reid’s family have described their loved one as ‘a gift’ and ‘full of life’.

Known as ‘Johnny’, the 20-year-old from Cinder Lane, Guilden Sutton, is survived by siblings Joanna, 27, herself a young doctor, David, 24, and Isabel, 17, a sixth former at King’s.

Dr Peter Reid, a consultant cardiologist at the Countess of Chester Hospital, told The Chronicle shortly after his son’s death: “You don’t get over something like this but perhaps you come to terms with it. As I said in my eulogy, his name meant ‘Gift of God’, he was a gift to us and although we would love to have kept him for longer, I think we have to be thankful for the time we had with him.

“I think he was a person who made an impact on people. He was a very warm person. For example, one of our neighbours said if they were sat out and Jonathan walked by he would always wave to them whereas many other people would walk by and wouldn’t.

“He had a lot of time for people and I think he was a breath of fresh air, full of life and enthusiasm, just very interested in the world in which he lived.”

The second year engineering student’s passionate desire to understand ‘how things worked’ began at a young age when as a two-year-old he turned the bathroom sink taps on full, causing a flood. According to his mum Julie’s poem about the incident, ‘I only wanted to know – where would the water go’.

Later Johnny’s interest in how things worked grew beyond the material and he loved to express opinions on everything from politics to global warming.

Johnny was musical, having learned both the piano and trumpet as a youngster. At school he played rugby and while on a gap year took up judo which he continued at university.

More than 200 people packed out his funeral at St Peter’s Church, Plemstall. Mourners included former King’s boys and the headmaster along with 35 student friends from the University of Sheffield where Johnny was studying mechanical engineering.

In 2011 Jonathan helped run a holiday club for young people at St Peter’s Church where he was friendly with Rector Rev Mark Hart, who conducted the funeral service, and his son Fred.   

Rev Hart told mourners: “And so it is in this confidence that we will today commend to God Jonathan Peter Reid, philosopher, political commentator, film producer, development engineer, destructive test engineer, pyrotechnician, stuntman and more.”

Donations at the funeral were in aid of The Children’s Society and the Church Army, chosen because both charities work with young people.