Johnny was funny, bright. He was so good-looking. But underneath all that, he was very ill.’ Johnny Baker, from West Bridgford , was a cheeky, sporty teenager who left a lasting impression on anyone he crossed paths with. At 17, however, his life took a turn when he had a hypomanic episode, followed by a referral to Child and Adolescent Mental Health Services (CAMHS), where he received help until he turned 18. But his family have said this was followed by inadequate support from adult mental health services, provided by Nottinghamshire Healthcare NHS Foundation Trust (NHFT). Seven years later, Johnny, aged just 24 years old, jumped in front of a bus on the A52, near Gamston Lock, on January 17, 2024. To this day, it is unclear what exactly caused his illness and, despite a number of failures identified by a coroner, Johnny’s mum said she has still not received a formal, direct apology from the trust as she spoke publicly for the first time about losing her son. “They acknowledged it was a very complex case,” Caroline Saxton told Nottinghamshire Live. “He was under CAMHS for a while, trying different bits of medication. He then turned 18 and was passed onto the Rushcliffe local mental health team. It all started to go horribly wrong from there.” Ms Saxton explained she felt she and her son were ‘fobbed off for years, constantly voicing their concerns about Johnny’s care but getting nowhere. In 2021, Johnny even took himself off medication and stopped engaging with the service, feeling like he wasn’t listened to by the professionals who had a duty of care to him. Ms Saxton said: ” Ever since he moved to the adult mental health team, we battled to get him the mental health care he needed but he never got it. “He felt there was no point in going to mental health services because he just got dismissed all the time.” No proper care plans and risk assessments, being overmedicated, and a complaint from Ms Saxton being passed back for review to the team she had complained about are just some of the issues Johnny and his mother battled with over the years, she says. January 17 wasn’t Johnny’s first attempt on his life, with a previous one in October 2023, which resulted in an admission to Sherwood Oaks Hospital in Mansfield . He was ultimately discharged before Christmas to a regular team of mental health staff, with his assigned care coordinator being a dance therapist who was not trained on suicide risk. The day before he jumped in front of a bus, Johnny told this therapist that he had suicidal tendencies. She never thought to disclose this to his consultant, however, with Ms Saxton saying the care coordinator was ‘adamant’ Johnny’s suicide risk was low. Ms Saxton said: “This was despite him threatening to take his own life and telling her he felt suicidal. “She said that because he hadn’t made a plan [on how to end his life], he wasn’t at imminent risk of suicide.” The mother explained mental health teams constantly tried to discharge her son before he ‘got a lot worse’ and was finally sectioned in November 2020. She said: ” You know when your child’s not right, don’t you? He didn’t think rationally and a lot of the behaviours were really shocking to everybody – apart from the mental health services. “We almost normalised some of them.” Ms Saxton explained how, after he was detained under the Mental Health Act for the first time, Johnny “ran down the road completely naked” and ended up in the lake at Holme Pierrepont Country Park. Johnny also went through phases of only eating meat and started a fire inside his mother’s home, with his condition progressively getting worse over the years. Ms Saxton said: ” I thought getting detained under the Mental Health Act would help him but it almost compounded the situation. “He was taken to hospital, given a lot of drugs that didn’t agree with him and then discharged to me again with no communication. “It was a constant battle. It was constantly getting worse.” Over the Christmas period in 2020, Johnny was discharged to the early intervention psychosis team (EIP), who then decided he didn’t have psychosis so he was transferred back to the regular team. Ms Saxton recalled: “All the time he was under the Rushcliffe mental health services, he didn’t have much consistency in his care. “They kept wanting to discharge him. Nobody was really monitoring his medication. One of the drugs gave him parkinsonism [a disorder causing movement issues similar to Parkinson’s disease]. He had no quality of life.” Despite asking for talking therapy, Johnny’s wish was never granted despite being on the waiting list ‘for years’, with medication used instead. Ms Saxton explained that talking therapy wasn’t available for Johnny under the EIP as he needed to have been in their care for a certain period of time. As he was passed “backwards and forwards” between teams, this meant he didn’t meet this threshold. Ms Saxton said: ” He never got a specific diagnosis for years and that’s one of the reasons why, in my view, he was passed from one team to another. “They were all based in the same building but there seemed to be no communication. It seemed none of the teams wanted him. “I don’t know if this was because this was too complex of a case for them so they wanted the other team to be responsible for him. There’s a huge catalogue of us begging for help.” An inquest took place into Johnny’s death at Nottingham Coroners’ Court in June 2024, with coroner Michael Wall finding a number of missed opportunities and failures by NHFT. The most significant of this was their failure to recall Johnny to hospital when it became obvious he presented a risk to himself. The coroner also criticised the trust’s record keeping, risk assessments and care plans, saying they weren’t updated when they should’ve been. Ms Saxton said: ” Johnny taking his own life was the culmination of us battling to try to get him the care he needed but not being listened to. “Despite the coroner’s findings, I’ve never had an apology or acknowledgement from the trust. “We saw the statement they sent to the media [after the inquest] saying they’re offering their apologies to the family but we never heard directly from them. “We’ve been asking for one for two years. It’s not surprising given the experience we’ve had with them over the years. “We never heard about what was implemented to stop this from happening to somebody else. They acknowledged that the individuals assigned to him did not have the proper training. “I think these failures will keep happening.” Ms Saxton is now pursuing a legal claim against the trust, not for the money – which would only cover the funeral expenses, but for an acknowledgement of Johnny’s death. She said: ” I almost feel insulted being offered some money from an NHS trust. This isn’t about the money in the slightest. “I just don’t want this to happen to anybody else, although it seems to be happening an awful lot. It has to stop somewhere.” A spokesperson for Nottinghamshire Healthcare said: “We again offer our heartfelt condolences to Johnny’s family and friends, and we again apologise for the aspects of care identified by the Coroner at his inquest in 2024, which were not of the standard Johnny deserved. “We are unable to comment publicly on an individual’s care and treatment due to patient confidentiality, but urge anyone with concerns about the care provided to a loved one to talk to us directly. “We are absolutely committed to an ongoing programme of improvement focusing on safety, quality and improving the experience of people who use our services and the communities we serve.