NHS trust admits failing suicide victim
A mental health trust has 'learned from its mistakes' following the suicide of death of a troubled young man, a coroner concluded.
Brandon McDonald, of Beech Road, Dudley, had been deeply affected by the deaths of his grandfather and a close friend, an inquest in Oldbury heard.
He was also upset by the recent break-up with his girlfriend, with whom he had a son, and had got into trouble with the police after breaching a restraining order to keep away from her.
The 20-year-old, described as having 'complex' mental health needs, was found hanging in woods near Canal Street, at the back of Dudley Zoo, on September 9 last year. Hours earlier he had sent his aunt a text message, saying: "I'm sorry, I love you all."
His mother Joanne McDonald, a civil servant, revealed that her son was diagnosed with Attention Deficit Hyperactivity Disorder(ADHD) as a youngster although did not take medication for it.
Later, aged 18, he started to experiment with recreational drugs, including cocaine. In 2016 his friend died in a car accident, a tragedy for which he felt partly to blame, the inquest heard.
His mother told the inquest that he had self-harmed in the past, and she had once found him with a ligature around his neck.
Mr McDonald, a labourer had gone to Bushey Fields Hospital, part of Dudley and Walsall Mental Health Partnership NHS Trust, about five weeks before his death following a 'bad weekend' but he was turned away, the inquest heard.
He had an appoint booked for August and was told he would have to wait until then to be seen. Mrs McDonald said her son had been 'really upset' and she had managed to get him a next-day appointment after appealing to her GP.
She added: "But there wasn't really a plan and they didn't speak to me."
She said his grandfather, with whom he had been extremely close, died in February last year, followed by his grandmother two days after the funeral.
Her last contact with him had been on the evening before his death when she and her husband had given him money to go out, when he had 'seemed fine', she said.
But she was unable to contact him the next day, and frantically phoned round his friends for news of him, learning only that he had been 'laughing and joking' the night before. Then at a local shop that evening she learned that a body had been found in nearby woods. "I knew it was Brandon," she said.
The inquest heard that the NHS trust admitted they 'did not fully realise the the extent of his true feelings' after holding an internal investigation and put in place an action plan to reduce the risk of a similar tragedy occurring.
Concluding that Mr McDonald took his own life, Black Country coroner Zafar Siddique said the trust accepted that it had fallen below its usual standards. "In my view they have learned from their mistakes," he added.
