Midlands Partnership NHS Foundation Trust has responded to the suicide of 26-year-old Liam Joseph Lyes-Watson after a coroner ordered a rarely-used ‘preventing future deaths’ notice compelling the trust to reply.
Liam's mum Diane Lyes and her partner Andrew Heaton had the agony of seeing Liam's mental health deteriorate as he lived at home with them in Trefonen, near Oswestry.
He had been especially upset by some strangers ridiculing him at an event in Chester in 2021 about the make-up he had been using to cover up a birthmark on his face.
Ms Lyes said: "He was in crisis but they said he wasn't. I told them on the day that he died that he was going to die at that point.
"At the very minimum what they should have done is come out and see him but they said he was not engaging with them. It wasn't like he was a bit down today, the risk was high that he would kill himself. He had the means to do it, he didn't respond but they just left it."
Ms Lyes says as a result of her son's death she has had to give up her own job working with people with Huntingdon's disease across Shropshire and Mid Wales because of the mental health element to it.
"I am not strong enough to support people any more," she said. Liam's father, Andrew Watson, had died when he was aged just two.
Ms Lyes's other son, Niall, 18, was incredibly close to his brother, and his step-dad Andrew Heaton, had also been crying at his work place, Ms Lyes said.
"My partner summed it up for me. He said: 'I actually felt worse from speaking to them'. There were no suggestions how we might keep Liam safe."
She added: "Nothing is going to bring Liam back but when the coroner asked them if they would do things the same, without hindsight, they said yes. I will be taking the issue up with the relevant ombudsman to get answers to the issues.
"I don't think I will ever reach closure - they did not make things easier for those who were left behind. We are planning an event next year to do something more positive but there are too many loose ends at the moment that being positive does not seem right."
Ms Lyes described Liam as "tall and a big, gentle giant" who had not been fazed by his birthmark when he went to Berriew school, or when they moved when he was aged eight to Trefonen. He then went to high school in Llangollen before studying economics and finance at Heriot-Watt University in Scotland where he was awarded a first class degree.
"He had been working as a finance graduate and wanted to work in stocks and shares," she said. "He was very good with numbers from a young age."
At uni he had to overcome mental health challenges. When he moved back to the family home he would travel to Chester to have his hair cut rather than take the risk of having his birthmark seen locally.
And he also had problems with forming relationships with women as he would worry about them seeing the birthmark when his "camouflage" wore off. He would not go swimming for the same reason.
Following an inquest on July 19, 2022, senior Shropshire coroner John Ellery issued a prevention of future deaths notice on the trust after agreeing that it was appropriate to consider what happened during phone calls made on October 20 and 25 last year. He had concluded that Mr Lyes-Watson's death was suicide with the medical cause of death recorded as fatal opioid toxicity.
Mr Ellery said: "The inquest heard that Liam had been struggling with his mental health in the weeks preceding his death. He and his mother, and subsequently his step-father, contacted the Access Team on October 20 and 25, 2021.
"Following the second telephone call by Liam’s step-father the call handler said that without Liam’s consent they could not take action and if the situation was acute they should ring emergency services as they had previously done on October 20, 2021."
He added: "During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken."
He had four areas of concern; that the call handler on the second occasion was not trained "and needed to take professional advice from a colleague which colleague did not then speak directly with the caller."
He was also concerned with the "apparent blanket response that they could not discuss the case with the caller yet they could take information from him" and said that "more should have been done."
Neil Carr, chief executive of the Stafford-based Midlands Partnership NHS Foundation Trust said: “I would like to offer my sincerest condolences to Liam’s family.
“Following Liam’s death the trust has carried out a thorough and detailed investigation to ensure that we learn from this tragic incident. I can confirm that the Access team has introduced further staff training and enhanced supervision to its call handlers.
“Significant work has taken place to reinforce the importance of concerns raised by family members. When these concerns are raised they are dealt with by the appropriate clinical member of staff on shift and actioned accordingly.
“I can confirm that telephone calls into the Access service are recorded for quality and assurance purposes and can be retrieved within 30 days. Moving forward we will use these recordings to access call information when serious incidents are reported.”
In a more detailed response seen by the Shropshire Star, the trust has told the coroner that "the call handler has attended a stress and resilience course to help them understand how to manage their own emotional responses to difficult calls received during their work."
Training has also been updated and addressed, they say.
"We have reviewed this case with shift co-ordinators and agreed that Liam should have been referred to the Crisis Team for them to make the decision about further action," they added.
"We recognise that the shift co-ordinator should have spoken to Mr Heaton and listened to his and Liam’s mother’s concerns. We apologise for this omission and learning from this missed opportunity has been shared with the team to ensure all attempts are made to reengage service users who disengage."
On the recording of phone calls they said: "The trust and the investigator apologise for mistakenly stating that the calls to the Access Team are not recorded.
"All calls are recorded and are kept for audit and quality assurance and kept by the company who provides the service for 30 days.
"The trust has requested that the company examine whether they can access the recording in question and will be reviewing whether calls can be kept for a longer period of time.
"In future it has been agreed that when an unexpected death is reported that the relevant call will be retrieved immediately and reviewed as a part of the investigation process."
But the trust's response adds: "Our Health Informatics Service has confirmed that we are unable to retrieve the specific calls in relation to this case due to exceeding the period of storage for such recordings.
"Calls recorded are erased automatically after 30 days and are not able to be retrieved. We have changed our process and following the notification of a serious incident within 30 days of contact with MPFT, the Access Team Manager will retrieve the calls related to the case and secure them in preparation for any subsequent investigation."
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