John Jones QC, a barrister who worked on high-profile war crimes trials at The Hague, died instantly in the collision in West Hampstead on April 18 this year, St. Pancras Coroners Court heard yesterday (Thursday).
Mr. Jones, a married father-of-two, was the head of international law at Doughty Street Chambers, Bloomsbury.
He had been admitted to the private Nightingale Hospital in Lisson Grove, Marylebone, in March, with a number of mental health issues, which had been given a "working diagnosis" of bipolar disorder and anxiety by his psychiatrist.
But the court heard that he spent the majority of the time alone in his room, refusing to attend therapy sessions or even eat in the communal dinning room.
Coroner Mary Hassell raised concerns about his treatment and said: "He was in his room, lying on his bed or on his laptop. That seems fairly awful in therapeutic terms. To me if I were worried about a person that was mentally unwell I would think that environment was the worst possible environment for them."
Ms. Hassell is to write to the hospital demanding changes she believes must be made to prevent future deaths. She said patients at psychiatric hospitals must be made to engage with therapy.
She said: "I think his failure to engage was part and parcel of his illness."
On the day before his death, Mr. Jones, who lived in had spent the day with his family, who had become increasing concerned about his wellbeing. The inquest heard that Mr. Jones may have been suffering from the side effects of withdrawal from his medication. He returned to the hospital, where he was a voluntary inpatient, that night, but at 5am the following morning he was allowed to leave the hospital after filling out his own risk assessment form.
Ms. Hassell questioned the efficacy of such a form, which she described as "perfunctory". She said: "Surely there will be in an incentive for him just to tick 'no I've not got a risk of this' and then just leave."
In a statement, read to the court, his father, Hugh Jones, said: "I was astonished he had gone out so early in the morning when he was in such a bad way."
Mental health nurse, Katie McTaggart, who agreed to let him leave, said he had shown no signs of being a danger to himself. The court heard that, under the Mental Health Act, she could have stopped Mr. Jones leaving if she was sufficiently worried about his state of mind. Questioned about allowing Mr. Jones to leave the hospital at 5am, Ms. McTaggart said: "We can't section someone because it's early in the morning."
She said the form was only "one aspect" of their risk assessment, adding: "We do constant risk assessments as nurses."
She said: "I didn't have any concerns about him having suicidal plans or planning to harm himself".
The court had heard that Mr. Jones, who lived in Hampstead Garden Suburbs, struggled to continue to work as his condition worsened. He had represented Julian Assange as the Swedish government attempted to extradite the Wikileaks founder. Among his other clients were Saif Gaddafi, the son of the fallen Libyan leader, and Charles Taylor, the former Liberian president serving a 50-year sentence.
At the time of his death, he was described by colleagues as a "brilliant and creative lawyer".
Doughty Street Chambers said in a statement: "John was admired and appreciated for his amazing sense of humour, his professionalism and his deep commitment to justice and the rule of law."
Returning a narrative determination, Ms. Hassell said that she had no doubt he intended to jump in front of the train, but added: "The state of his mental health at the time meant he lacked the necessary intent to categorise this as suicide."
She said: "It seems to me that at the time of his death he was actually very poorly."
She said that CCTV footage proved that he acted alone, adding: "I rule out completely the action of any other person."
Comment: 'Very poorly' is all very well for lesser ailments, but it's not cutting the mustard as an explanation for what went on here. Some CCTV may show him alone, but given that all London is 'under the watchful eye' of Big Brother, let's see if the rest of the footage points to the involvement of others.