A year to the day since a Norwich man with schizophrenia died from a heroin overdose, his mother has said she should have been lighting a memorial candle instead of looking for answers.
Leo Jacobs died on November 14 last year, and today (Tuesday) senior coroner Jacqueline Lake gave the conclusion it was drug-related.
But his mother Sheila Preston, a governor with the region's mental health trust, said she was disappointed and felt she had 'failed'.
Speaking after the inquest, held in Norwich, Miss Preston said: 'Leo was Jewish and today I should be lighting a 24-hour candle for him, instead I've been here fighting for justice.'
During the two-day inquest, Ms Lake heard 39-year-old Mr Jacobs had suffered with paranoid schizophrenia for around 20 years and was under the care of Norfolk and Suffolk NHS Foundation Trust (NSFT).
But for eight and a half weeks before his death, Mr Jacobs had not been in face-to-face contact with a mental health professional.
Dawn Lark, Mr Jacobs' care coordinator, said the last time she saw Mr Jacobs was September 14, 2016. She said: 'I do agree it is not ideal. It was a combination of certain factors.'
She added: 'At the time I did not have huge concerns for Leo, things had settled down for him.'
She also said Mr Jacobs had denied he was using illicit drugs. But Miss Preston said she held NSFT responsible. She added: 'I believe with sufficient care and treatment Leo would be alive today.'
Friends of Mr Jacobs said he was being cuckooed. James Thackray said: 'It's when a group of drug dealers prey on vulnerable people who are normally taking drugs themselves. They will pressure them to use their flat to use as their station of business.'
Before Mr Jacobs was found dead in his flat in William White Place, Mr Thackray and others said these 'lads' had visited him.
Summing up the evidence, Ms Lake said: 'I have heard no evidence to lead me to believe NSFT knew or ought to have known at the time of a real or immediate risk to his life.'
Miss Preston added: 'The only reason I actually have been a governor and spent 20 years devoting myself to trying to affect better treatment of people with the mental health conditions is not only for my son, it's for people of Norfolk and Suffolk. But I feel like I've failed.'
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