A young man with floppy blonde hair sat next to me taking notes frantically. He had a massive folder on his desk. When I looked carefully at the writing on the spine of the folder, it read, “Master File Dr GP (Mr SN – Deceased)”

I sat in the courtroom looking at that label for a long time, thinking once again about the drama of life – a room full of people looking really solemn discussing the nitty-gritty of a young man having ended his life. For a while, I couldn’t hear any sounds but I could see lips moving and heads nodding. It was surreal. Once again I was looking in from the outside while sitting in the room. Was it me or was it him?

It was a gentle and compassionate process despite which the day felt very long and exhausting! A few glaring facts came into light – it was not clear to the GP that this patient had been discharged to him with the diagnosis of Bipolar Disorder. Apparently the discharge summary only made a passing remark on “Royal College of Physicians leaflet on Bipolar Affective disorder was given to the patient” without specifying Bipolar as the working diagnosis.

The presence of 3 lawyers in the room made the atmosphere quite tense and defensive but underneath that exterior, I could see the humanity and fragility of all concerned. At one level, I know that it is really important to examine each detail closely to stop this from happening again but at another I feel like there is no point. It’s too late for us anyway. Every new fact is painful. I know it’s selfish to think like that. But I am selfish. I would like something in return for going through all this pain but there is nothing at the end of it, if it ever ends.

It’s not over yet. Part 2 of the inquest will be in mid-november. Well. We are where we are.