This is what I want to say in court tomorrow:

“Once again, we have found the same shortcomings as have been discovered in previous inquests related with suicide. The story is different but the themes are the same – various parts of the NHS not talking to each other, risk of suicide not being assessed properly and safety plans not put in place, training in mental health for GPs being inadequate, support for families being poor and follow-up after discharge from specialist services being completely not pro-active. Same things …. again and again.

Clearly, the findings from previous inquests have had minimal bearing on practice so far. Will this one be any different? Do we have the time, money or will to look after patients with mental ill health properly? Does it really matter to us as a society, as a country?

Given that suicide kills more young people than AIDS, road traffic accidents and violent crime put together, we have a long way to go. Let’s wake up and educate ourselves. Let us demand better care for ourselves and our loved ones. In the case of suicide, prevention is cure. If not prevented, it is too late, too final and too painful.

We all matter. Each one of us.

To quote Sir Liam Donaldson from 10 years ago –

“To err is human.
To cover up is unforgiveable.
To refuse to learn a lesson is inexcusable.”

Love you Saagar. Rest in peace my darling.