A young man took his own life after healthcare services failed to recognise he was in an 'coercive and controlling' relationship with a man 40 years older than him. Thomas Jayamaha, 23, was found unresponsive by his partner, who was in his 60s, at an address in Sherwood on February 28, 2022.
Emergency services were called to the property by Thomas' partner, but he did not respond to CPR and was declared dead at 8.02pm. After attending the scene, Nottinghamshire Police became aware of allegations that Thomas' much older partner had been exerting control over him in the last years of his life.
Officers also noted the unusual living arrangement at the home, leading to a lengthy police investigation which resulted in the arrest of the man on suspicion of controlling or coercive behaviour on April 14, 2022. However, the criteria for criminal prosecution was not met.
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An inquest into his death concluded on March 15, after assistant coroner Dr Elizabeth Didcock heard evidence over a period of four days at Nottingham Council House. It detailed that Thomas, who had autism spectrum disorder, had struggled with suicidal thoughts for years and had been in a coercive relationship with a man more than twice his age.
An autopsy examination found no injuries typical of historical self-inflicted injuries, any that indicated he was restrained against his will, or that he was the victim of blunt or sharp trauma assault. However, a toxicology report identified the presence of a drug in his blood and urine samples, the level of which was noted to be significantly over the lethal dose.
According to the assistant coroner, detectives from Nottinghamshire Police highlighted evidence from Thomas' tablet showed he had visited websites that discussed suicide.
Dr Didcock noted Thomas' family and others had been concerned his relationship was controlling and that this had played a role in his death. This concern over the nature of the relationship was shared by the Department for Work and Pensions and Nottingham City Council's adult social services.
Thomas' parents had no contact with him in the four months prior to his death and had limited contact after he left home aged 17, the inquest heard. During one referral to adult social services, Thomas said he did not think he was in an abusive relationship, with a social worker commenting his autism diagnosis did not impact on his capacity to make decisions about his living arrangements and relationship.
But the early findings of a Domestic Homicide Review, which looks into the circumstances when someone's death appears to have resulted from violence, abuse or neglect from a partner or household member, signalled there was "likely evidence of coercion and control" such as the CCTV in the house, mobile phone tracking, the giving of unprescribed medication, changing Thomas' phone number, and isolating him from his family. Other early findings were that physical abuse may have been disguised as play fighting, that Thomas appeared to be criticised regularly and there may have been financial abuse.
The author of the review said some services were focused on a single issue and made no links between controlling behaviour and his mental health. The review also noted that while Thomas' GP provided care that was "above and beyond", other services lacked understanding of how autism had affected his understanding of relationships.
Dr Julian Henry, who was Thomas' GP from 2016 until his death, described him as a "troubled young man" but said he was charming and affable. Dr Henry told the inquest Thomas had attended the early consultations with his much older partner, and at this time it looked like he had rescued him in an altruistic way, but this perception changed over time.
Dr Henry felt Thomas struggled with what he saw as two possible ways forward - to remain with his partner or return home to his family. He said this would be difficult as Thomas' family did apparently not accept he was gay and had threatened to send him to live with relatives in Sri Lanka, where homosexuality is illegal, before.
He was prescribed antidepressants but these did not improve his symptoms, and he grew frustrated with the back and forth of referrals to Nottinghamshire Healthcare trust over the years, according to his GP. The assistant coroner said Thomas faced repeated rejection from the Trust, as his care was impacted by a lack of communication between different services and no senior Nottinghamshire Healthcare trust member contacting his GP.
She found they did not understand he was in a coercive and controlling relationship and that this was likely a risk factor for his suicidal thoughts and previous suicide attempts. Thomas made multiple calls to the trust's crisis team before his death, but when a final plan was decided in January 2022 to refer him for stabilisation work, this was then not communicated to him or his GP.
Dr Didcock said: "I find all of these issues that I have identified to be clear omissions of care by the Trust, they are serious and there were many opportunities to provide Tom with necessary and better care." However the assistant coroner found it a "struggle" to say if better intervention would have prevented his death, due to the challenging factors in his life.
Officially concluding the inquest, the cause for Thomas' death was recorded as suicide. Dr Didcock added: "Finally I wish to extend my sincere condolences to Tom's family and his friends and all who knew him and were close to him, I am so sorry for your loss."
Dr Didcock highlighted an internal investigation carried out by Nottinghamshire Healthcare Trust found some shortcomings, particularly that no one team got a grip of the case and that staff needed to be more curious about his domestic situation. But this investigation only covered the last four months before his death, with the assistant coroner criticising its "limited scope".
The inquest was told a Regulation 28 letter would be sent to the Chief Executive of Nottinghamshire Healthcare trust, setting out the matters of concern. These were listed as the detailed progress of the autism strategy work at the trust, insufficient complex case management progress, and the serious incident investigation process, with Dr Didcock adding: "In my opinion there is a risk that future deaths could occur unless action is taken in these three areas."
Ifti Majid, Chief Executive of Nottinghamshire Healthcare NHS Foundation Trust, said: “On behalf of the Trust, I once again extend our sincerest condolences to the family and friends of Thomas Jayamaha for their loss.
“We are considering the very detailed Coroner’s findings and had already made a number of changes, including a new referral process and daily triage meetings. We will continue to build on these developments to address the recent concerns raised by the Coroner including the understanding of the level and complexity of risk presented to Thomas so that the experience for future patients is improved.”
