Preventing further deaths is driving a city mum's calls for lessons to be learned by mental health services, following the death of her 21-year-old son.
A pre-inquest review into the death of Kurtis Ward, who lived in Norwich and was found dead on July 2 last year, was held at Norfolk Coroner's Court.
Described as "a beautiful soul" by his mother Rachel Spinney, the youngster had autism, anxiety and a precancerous condition, and was a carer for his younger sister.
Miss Spinney said: "He was interested in politics and social justice. He had so much to give."
Jacqueline Lake, the county's senior coroner, held the review on Wednesday after a statement from Mr Ward's mother raised concerns over the lack of recognition by the county council of her son being a carer for his sister, now aged 18, who has complex needs.
The trained counsellor also raised the fact that Norfolk and Suffolk Foundation Trust (NSFT), which Kurtis was referred to in 2017 and self-discharged from in 2021, did not alert her to three attempts to self-harm and potentially take his life.
Mrs Lake wanted to find out when he disclosed that information to NSFT mental health workers and what happened to the referral to adult social services in June 2022 after a review by Carers Matter Norfolk.
Miss Spinney said: "I should have been informed of Kurtis' suicide risk."
She added the Carers Matter assessment was done "right at the time when we were in a critical situation. Kurtis was shutting down in acknowledging the difficulties he was facing".
Miss Spinney said her son's death took place just days after a county council-led Preparation For Adult Life team panel turned down an application for her daughter to have supported living accommodation - which was later overturned.
His death also happened days before he was due to start a care assistant apprenticeship at the Norfolk and Norwich University Hospital.
Miss Spinney, 51, continued: "I fear for families and feel carers are being slung into a situation where they don't have control or a voice. This isn't a blame game.
"It is about organisations collaborating and understanding the holistic family situation, particularly for carers.
"It is about what can be done to prevent future deaths and how to support people with complex needs."
'Sincere condolonces'
Stuart Richardson, chief executive at NSFT, said: “We would like to offer our sincere condolences to Mr Ward’s family for their tragic loss.
"As this is an ongoing inquiry, we are currently complying with the coroner’s office ahead of the full hearing.”
A Norfolk County Council spokesman said: “Our thoughts and sympathies are with the family at this very difficult time. We would not want to pre-empt the outcome of the inquest so cannot comment in detail.
"We commission a range of support for carers, including well-being advice and information, as we understand that it is both a difficult and vital role.
"We are always encouraging more people to let us know that they are carers, so that we can make sure they have access to the support that is available.”
The inquest is expected to resume this summer.
- If you need help and support, call Norfolk and Suffolk Foundation Trust’s First Response helpline on 111 and select mental health option or the Samaritans on 113 123. Both services are available 24 hours seven days a week.
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