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Inquest into the death of Justin barrett


We acted for the family of Justin Barrett, who was aged 45 when he tragically took his own life on 25 September 2019 as an informal patient on Sapphire Ward at Highgate Mental Health Centre.

An inquest touching upon Justin’s death was heard before the St Pancras Coroner’s Court from 17 – 19 November 2020. In a narrative conclusion, the Coroner’s Record of Inquest found that “there was inadequate record keeping on Sapphire Ward, but this did not impact on the level of observations.”

After the inquest, we wrote to Camden & Islington NHS Foundation Trust on behalf of the family seeking an apology for what happened to Justin. The family’s concerns have always been that the Trust was negligent in the care it gave to Justin and to make sure that the same mistakes were not repeated so as to spare other families from the distress they endured from the loss of their loved one in preventable circumstances.

On 19 May 2022, Camden & Islington NHS Foundation Trust accepted liability in negligence for Justin’s death. The Trust accepted the family’s claim in full that it had breached its duty of care toward Justin by:

  1. Removing 1 to 1 observations the day before he died, on 24 September.

  2. Failing to inform nursing staff responsible for Justin’s observations that he had attempted suicide by ligature just three days before, on 22 September.

  3. Failing to remove all possessions and clothing which presented a ligature risk after his attempt on 22 September.

  4. Failing to resolve the ligature risk posed by the en-suite doors, which was known to the Trust years before his death.

The Trust have since paid a financial settlement to Justin’s family, 100% of which has been donated to charity.

In a letter of apology dated 27 January 2023, Chief Executive of Camden and Islington NHS Foundation Trust, Jinjer Kandola MBE, said:

“I understand that a number of issues have been identified about the care that your brother received, including that it was not reasonable to step down your brother from one-to-one observations on 24 September 2019. There was also a failure to promptly replace the en-suite bathroom doors, which were an identified ligature risk, as well as a failure to remove personal possessions from Mr Barrett that were a potential ligature risk. I understand that these failures may have provided Mr Barrett with the opportunity to take his own life, which may otherwise have been prevented. I want to say that I am very sorry for the mistakes made in your brother’s care. I can only begin to imagine the distress and discomfort that this has caused you and your family.”

Justin’s family would like to thank the INQUEST charity for all of the support they have given since Justin’s death and for whom they will be forever grateful.


For more information, please contact Daniel Cooper at or 020 7404 3004.


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