Day 389

This day last year, a memorial service was held for my son at the Great Hall of his former school. It was a deeply moving occasion, filled with love. More than 250 people attended. He earned more love in his 20 short years than some people do in a lifetime.

The Coroner’s inquest into the suicide of my son is still unfinished but as his mother and his prime carer here are a few facts.

  1. An Honorary Consultant Psychiatrist saw him 3 weeks into his illness and made a diagnosis of Bipolar Disorder.

Did he speak to any of the family members/carers about this diagnosis and what it might mean for us as a family?
Did he send him home?

  1. His GP was the only one who knew he was severely suicidal for at least 4 weeks before he died as he did not mention it to anyone else.

Did he tell any of the family members/carers?
Did he send him home?

  1. The handover from the psychiatric team to the GP should have highlighted the diagnosis.

Did the letter tell the GP about a new diagnosis of Bipolar Disorder?
Did it tell him to watch out for depression?

  1. The trainee psychiatrist who wrote the discharge letter to the GP must have seen my son at least once.

Had he?

Am I surprised now that my son is dead?
I am surprised that he lived for as long as he did. He followed every instruction he was given and took his medications religiously. He really wanted to get better.

He just didn’t get the care that he deserved, from the specialist services, primary care services or his parents. All of them failed to talk to each other in a way that would keep him safe.

In theory, the NICE guidelines say that carers should be given written and verbal information about the diagnosis and management of Bipolar Disorder, about positive outcomes and recovery and about the social and psychological support available for them. They encourage a ‘collaborative approach’ respecting the interdependence between the patient and their carers.

In practice, none of the above took place.

It was as if the existence of carers, in this case his parents, was not acknowledged. I felt that my concerns regarding his ill health fell on deaf ears.

I believe that unless families and carers are empowered with inclusion and information, young people will continue to die unnecessarily. Unless primary and secondary care services work in unison with each other and with the carers at home, patients will continue to fall through the gaps. This is not the first time it has happened but no lessons have been learnt.

I would not wish this nightmare on any family and I want to do everything I can to highlight the areas where we can improve care. Suicide is the biggest killer of young men all over the world and the numbers continue to rise every year. We as a community need to educate ourselves and help young people. We need to ask more questions. We need to demand better care for our children and other close relatives and friends.

Carers care. He was my only son. His well-being was on the top of my list of priorities. I had a right to know about his diagnosis and his suicidality in order to look after him properly.

He did not get to celebrate his twenty-first birthday.
I miss him every minute of everyday and I always will.

One thought on “Day 389

  1. I am so sorry to hear about your loss. I know all too well the heartache of such a death as I lost my youngest and only son to suicide six years ago. He was twenty-nine. The pain is unbearable still but I have learned to cope with God’s help. I hope you will find peace as time wears on.


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