Chamber and committees

Petitioner submission of 13 September 2021

PE1871/E - Full review of mental health services

Seven months have now passed since I found my precious son, Garon John Dalton, aged 22 years dead in his bedroom by hanging on 5th Feb 2021.

Less than three weeks previously, he had went with intent to a deserted place to do the deed with a rope but couldn't go through with it. He was met in the early hours in the kitchen by a member of his family holding the rope when he came in the front door. As soon as our GP surgery was opened I called and explained everything to the doctor who in turn spoke with Garon. It was decided that Garon would be referred to mental health crisis team so later that day they called to ask Garon to visit in person at a local NHS centre at 5 o clock where he was met with two CPNs alone.

About six o’clock I received a call from one of the CPNs telling me that Garon was on his way home, that he was in a bad place. The doctor explained that he had opened up to them and spoke about things he was going through and that the hospital ward was experiencing an outbreak of covid, so she couldn’t admit him but he promised he wouldn't do anything stupid and trusted his parents to look after him. OH, but, if she really felt he needed to be admitted she would have found him a bed somewhere!! So the plan was that the day shift team would call the next day but if Garon was feeling at risk of suicide to call 999. I asked, so have you given him medication and was met with no.

We as a family were on suicide watch...terrified of taking our eyes of our boy.

Yes, day shift called and spoke briefly to Garon. They told me that he would be assigned his own CPN within a fortnight. I was told that Garon would be assessed by his own CPN and she would decide the next course of action. Frantically I called my surgery again and pleaded for help but was told it was out of the doctors hands now. The crisis team and CPN would make the decisions regarding Garon's treatment.

Garon was not previously known to mental health services but had been on two occasions previously to our own GP regarding his mental health. The first time he was 17 and was met with a response of "Get your head out of your arse". I tell no lie, my son was crushed and dismayed, left hopeless and ashamed. The second time a few years later, after great persuasion from myself and agreement that we would get a different GP. On this occasion he was given a course of anti-depressants.

So, within the two weeks we did receive a call from a CPN who introduced herself as the same individual from before. On hanging up the call from her Garon lay back on his bed and said "It's no use Mum. She isn't going to help me, she doesn't care. I can tell by her voice.” I asked if she had mentioned medication but no, she hadn't. He was told to download a sleep app and that she would post out some self help leaflets. Besides myself with confusion I finally managed to track her down to be told that it wasn't protocol to prescribe medication and that she would go down the route of talking treatment. No leaflets appeared at our door and a few days later I called again to beg for medication. I was met with an apology that the paperwork hadn't been posted as there was a problem with the printer and that she would drop an envelope off to the home that night.

The leaflets were unacceptable...for a young man who was ill and who could hardly lift his head up, to be expected to read any of the irrelevant information within that envelope was appalling. Squeeze an orange...look out a different window...listen to music...play with playdough. For someone intent on taking their life. How dare she! Not to mention the poor quality of the print! A copy of a copy?

A few days later I went into his bedroom to find him...long hours dead…by hanging.

Why? No Medication. Inadequate and failed risk assessment. Non admittance to hospital. Sent home when less than 24 hours previously he tried to take his own life. I wasn't listened to…his main carer...a devoted mother to a poor, sick son. Why these failings? So now we are left as a family broken by trauma and grief, seeking support from a charity called FAMS. A charity that provides face to face support during a pandemic when my poor boy received nothing that I can even call support over a phone. My boy was failed from beginning to end...failed by a system not fit for purpose.