A 29-year-old man who cared for his dying mother took his own life after being sent home from A&E during a mental health crisis.
Jack Davies, from Gloucester, attended A&E multiple times in the days before his July 2023 death after suffering a mental health crisis that had left him thinking people were trying to kill him, his grieving grandmother said.
Ann Davies said her grandson - who had become the main carer for his dying mother Michaela Davies - had sought help from Gloucester A&E several times before his death having struggled for months.
“He did everything for his mother, and he was let down by the system. Nobody wanted to know,” she said.
A day after his final visit to A&E Mr Davies’ mother, who had terminal cancer, found his body at home.
A coroner ruled before his death he was suffering from “considerable confusion” and delusions and had stated he wished to be sectioned under the Mental Health Act.
Speaking with The Independent his grandmother has claimed NHS services failed to help him when he sought help.
“That’s my two children I’ve lost…Jack did everything for his mum. He changed his job. He gave up carpentry and took another job so he could be home to see to his mother,” she said.
“[After he died] my daughter just gave up … I’ve lost two within 10 months of one another. I know it’s bad enough to lose one, but you know you lose two like that.”
Mr Davies’ story comes after health advocates and experts accused the government of failing to prioritise mental health service funding. They told ministers that changes to the Mental Health Act, such as ensuring patients a choice over their care and discharge plans, would only be a “lip service” if not backed by additional investment in community mental health support.
Earlier this year safety watchdog the Health Services Safety Investigation Branch also warned NHS mental health services are placing critically ill suicidal patients at risk of harm by using inaccurate suicide assessments and ignoring warnings over early discharge from hospital.
According to a review into his care by the Gloucester Health And Care Foundation Trust, Mr Davies attended A&E on 6 June 2023 and was found by mental health staff to be a “priority two patient” meaning he suffered from hallucinations, delusions, paranoia and suicidal thoughts. He had suffered a relapse following two months of sobriety from substance abuse.
On 12 July he attended A&E again and was deemed a priority two risk.
In the two days leading up to his death on 25 July, Mr Davies, who had been receiving support from substance abuse services in his local area, was taken to A&E again after he travelled to a car park threatening to take his own life.
According to the review, he was seen at 7:38 am the next day, and sent home 30 minutes later, but was taken back that evening after he went to a Post Office asking for help because he thought people were trying to kill him. Staff at A&E then assessed him as a priority three risk, however, he was discharged without notifying the mental health team.
A day later he was found dead in his home. No illicit substances had been found in his system following his death.
A serious incident report by the trust showed no evidence that staff had carried out a formal mental health risk screen on his first visit. However, the report states an appropriate assessment was given to the young man on his subsequent visits.
Concerns raised in the trust’s report included that one staff member amended Mr Davies’ medical records after his death and that he was sent home on 26 July without being seen by a mental health team clinician.
Ms Davies claimed he had been calling for help from NHS services for months, having struggled with his mother’s terminal diagnosis.
“He didn’t have a chance. His brain and his worry must have just taken over him … the last three, four months, or whatever it was, he was asking for help, he wanted people to understand how he was feeling, and he just got nothing,” she said.
A spokesperson for Gloucester Health and Care Trust said: “This was a tragic case and our sympathies are with Mr Davies’ family and friends. We carried out an extensive review following Mr Davies’ untimely death and any learning from that has been embedded into our practices, in the hope that we can prevent similar outcomes in the future.”
If you are experiencing feelings of distress, or are struggling to cope, you can speak to the Samaritans, in confidence, on 116 123 (UK and ROI), email jo@samaritans.org, or visit the Samaritans website to find details of your nearest branch.
If you are based in the USA, and you or someone you know needs mental health assistance right now, call or text 988, or visit 988lifeline.org to access online chat from the 988 Suicide and Crisis Lifeline. This is a free, confidential crisis hotline that is available to everyone 24 hours a day, seven days a week.
If you are in another country, you can go to www.befrienders.org to find a helpline near you.
