We must demand change so no one can be treated the way Luke Johnson was again

Posted by Rosie Brighouse on 10 June 2016

On 17 July last year, Michael Gove gave a speech in which he described HMP Pentonville as “the most dramatic example of failure within the prison estate”.

Referring to the findings of a recent report, he spoke about the prison’s “blood-stained walls, piles of rubbish and food waste, increasing levels of violence, an absence of purposeful activity and widespread drug-taking” – before calling for fundamental reform of the prison system.

Luke Johnson

At the very moment the Justice Secretary was giving that speech, a 34-year-old man named Luke Johnson was being detained unlawfully at HMP Pentonville.

He had been there since 12 June, when he was sent to the prison after spending a few months receiving hospital treatment in a psychiatric intensive care unit. He was moved from the hospital to the Crown Court to be sentenced for an attempted burglary – the most serious offence he had ever committed and one that was markedly out of character for him.

Luke should have been released immediately after sentencing, free to go from the court. His time on remand meant he had already served the sentence he was given.

Instead, he was returned to prison and held there until 11 August. On that date, prison staff realised their mistake – and Luke was suddenly and abruptly turned out onto the streets.

He was dead within a matter of days.

Luke was a very vulnerable man who had struggled with serious mental health problems since his teenage years.

He was the much-loved son of Greg and Paula, with three younger brothers and a supportive and loving wider family. He was a black belt in judo, creative, artistic and a talented mechanic with a keen interest in science.

He spent the whole of his adult life relying on his family’s support as they did whatever they could to try to help him to lead a normal life. This was made more difficult because Luke struggled with drug and alcohol problems for many years and, even when forced to be clean in hospital and in prison, still suffered from acute mental ill-health, including symptoms of psychosis.

The psychiatrist who treated Luke at HMP Pentonville has suggested that his misuse of drugs and alcohol may in fact have been his way of dealing with the distress caused by his mental illness.

Let down at every stage

As part of my role at Liberty, I have had the privilege of helping Luke’s parents find out more about the circumstances surrounding their son’s death and whether it could have been avoided.

The inquest into his death took place this week at Chelmsford Coroner’s Court. We used the Human Rights Act to help to persuade the Coroner to hold a wide-ranging inquiry into what happened, during which Greg and Paula heard evidence about:

  • the prison’s failure to respond to numerous attempts by Luke’s solicitor to tell them they were imprisoning him unlawfully
  • Luke’s unstable mental state in the days leading up to his release
  • the fact that his sudden and unplanned release undermined clinicians’ ability to look after him properly
  • the lack of a proper handover of his care from the prison’s psychiatric team to his community psychiatric team
  • and the failure of the community team to follow up with him effectively in the days following his release.

They heard that, despite Luke’s own attempts to seek psychiatric treatment, he was let down at every stage – and he ultimately died from a heroin overdose at some point in the days before his body was found on 20 August.

The sheer scale of the failings in this case is truly shocking. Not only was Luke falsely imprisoned for two months in the worst prison in the country, but the Coroner has also ruled that Luke’s right to life – protected under Article 2 of the Human Rights Act – may have been breached.

The inquest jury also found that the actions of the prison and community psychiatric teams were inadequate, and that the lack of communication between the agencies involved in Luke’s care contributed to his death.

In January of this year, the Prime Minister promised a revolution in mental health services. He said: “I want us to be able to say to anyone who is struggling, ‘talk to someone, ask your doctor for help and we will always be there to support you’”.

That just wasn’t the case for Luke.

Working with Luke’s parents, we hope to use what we have learned from his inquest to call for changes to the way people like Luke are treated in the future.

Any of us could suffer from mental illness. None of us deserve to be treated the way Luke was.

Rosie Brighouse

Rosie Brighouse

Legal Officer