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Suicidal teenager 'let down by system'

PUBLISHED: 07:07 08 April 2008 | UPDATED: 19:03 10 March 2010

A MOTHER claimed last night that her teenage son had been let down by the mental health system after major concerns over the care he received before his suicide were raised by a coroner.

A MOTHER claimed last night that her teenage son had been let down by the mental health system after major concerns over the care he received before his suicide were raised by a coroner.

Greater Suffolk Coroner Dr Peter Dean urged healthcare professionals to learn important lessons from the death of 17-year-old James Chaston who was found hanged in a public toilet block in Beccles.

An inquest at Lowestoft heard a community psychiatric nurse (CPN) was the only mental health professional to see James in the two months leading up to his death, despite his parents raising fears that he was considering suicide.

Concerns about the assessment of James's condition when he took an overdose and cut his wrists five months before his death, in February 2006, were also raised.

Yesterday's inquest heard bosses at Norfolk and Waveney Mental Health NHS Trust and James Paget University Hospital (JPH) were introducing new measures to improve treatment in the light of James's death.

After the hearing his mother Jean Chaston said: “I feel very let down. James was let down.”

James's father Paul Chaston added: “If this inquest leads to changes, then it would have been worth our while standing up and being counted.”

The inquest was told that James, of Gillingham, near Beccles, took his own life because he feared mental illness would lead him to harm his family. However, doctors were unable to make an exact diagnosis of his condition.

His parents only became aware of his problems when he took an overdose and cut his wrists on September 3, 2005. James, a pupil at Notre Dame High School in Norwich, was treated and assessed at the JPH before being placed in the care of an acute mental health unit, although he was never formally admitted to hospital.

He was later transferred into the jurisdiction of the mental health trust's early intervention team, but was only monitored by a CPN, Ian Bell, during the final weeks of his life.

Mr Bell said he discussed James's condition with approved social worker Clare Pratt but it was felt he did not require a psychological assessment under the terms of the Mental Health Act.

The inquest was told that a decision was taken not to admit James to hospital in November 2005, because he would not benefit from this. However, his family claimed he wanted to be admitted.

Coroner Dr Dean said: “I am concerned about the complete lack of psychiatric care during this period. It comes across this chap (the CPN) was looking after James in total isolation.

“Mrs Chaston felt there was a change and that James was intending to take his own life. It seems to me that should have triggered closer attention to circumstances.”

A letter from the mental health trust revealed a number of new measures had been brought in. A senior psychiatrist will now have to review cases within a month of patient's being transferred out of acute care; the opinion of a second psychiatrist will be sought where the exact nature of a mental illness remains unclear and extra risk management training would be given to staff.

The JPH said it would also strive to make improvements after concerns that James's level of risk was underestimated when he was admitted in September 2005.

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