A 32-year-old with Asperger's and emotionally unstable personality disorder took his own life when NHS 111 call handlers hung up on him after months of 'frustrations' with mental health services.
At the inquest into his death, John Worthington's parents have said their son was 'failed' for years in his search for help.
Norfolk Coroner's Court heard how;
-John had to wait almost five months for a mental health assessment
-A GP criticised the delay from the 'chronically underfunded' mental health services
-John was told to call the NHS 111 service but they hung up on him when he struggled with a speech impediment.
The court heard how John had been expressing suicidal thoughts since 2014 but was only diagnosed with emotionally unstable personality disorder and generalised anxiety disorder in October 2016.
By the summer of 2017 he had reached a crisis point and called NHS 111 four times in the early hours of June 6.
A pathways advisor terminated the second call and during the fourth call John made an attempt on his life. Paramedics were dispatched and police gained entry to his flat at St Augustine's Gate in Norwich.
John was resuscitated and taken to the intensive care unit at the Norfolk and Norwich Hospital (NNUH). But the brain injury he had sustained was so severe he did not survive, eventually passing away on August 11.
The electrician and former nightclub manager had spent two years trying to get help from mental health services, and saw his GP 29 times in a single year.
John's father Keith Murdoch said: 'He liked to fix things and the one thing he couldn't fix was himself.'
The court heard John had to wait almost five months for a psychological assessment after two referrals in December 2016 - from his GP, Dr Henry Jones from UEA Medical Centre, and the mental health liaison team at NNUH.
An appointment was not arranged until May 10, which John missed. He failed to make the next appointment on June 21.
Dr Jones told the court: 'When he was referred we made it clear there was an underlying suicidal ideation. He told me a number of times when he was angry or annoyed he might feel like doing something.'
He added: 'John was referred on December 19 and given an appointment on May 10. That is about a week shy of five months. There is no guarantee patients will be seen within 28 days but under ideal circumstances it would not be another four months for someone to be offered an appointment. The risks were made known and clearly stated on the referral.
'The fact is [NSFT] are saying they are chronically underfunded. It is my experience as a GP who has worked in two practices with a high prevalence of mental health issues it can be sometimes very difficult.'
MORE: Mental health services had 'insufficient resources'
James Forrest, charge nurse at the mental health liaison team at NNUH, met with John at A&E on December 21, 2016 after he had again threatened suicide.
'He described frustrations he had experienced trying to access mental health services for a two year period,' Mr Forrest told the court. 'It was his experience of trying to access mental health support that led him to feeling suicidal.'
Jayne Burchell, mental health practitioner with NSFT, received the two December referrals.
She told the court there was 'no evidence of acute mental disorder' at the time.
John was placed on a patient of concern list at the GP and given an admissions avoidance care plan to avert the need for A&E attendance.
But facial ticks which accompanied John's functional facial movement disorder meant he often struggled to speak.
On June 6 he called NHS 111 but was met with pathways advisors who 'did not communicate effectively, professionally or with appropriate warmth', according to a service delivery report from IC24.
During one call, according to transcripts seen by this newspaper, he told the call handler: 'You're terminating the call because you are not patient enough to listen to a speech impediment'.
A root cause analysis report of the incident from IC24 investigated four calls from John to NHS 111 between 2.12am and 2.53am.
'All of the calls received were difficult for all concerned,' the report said. 'The patient was suffering with communication problems and was finding it hard to articulate.
'This caused the patient to become incredibly frustrated with all who dealt with his contacts. Unbeknown to the call handlers the deceased was known to mental health services and had been directed to call NHS 111 by the local crisis team.'
The IC24 report added: 'NHS 111 were unaware of any existing mental health support plan for the patient. NHS 111 were unaware of the process for the mental health crisis team for patients to ring 111 before mental health intervention.'
Assistant coroner for Norfolk Johanna Thompson recorded a narrative conclusion.
Definite failings
After the inquest, John's parents, Keith Murdoch and Samantha Harrowven, said their son was a 'wonderful young fellow' who had been failed by mental health services.
'There were definite failings with the NHS 111 calls', said Mrs Harrowven.
'The clinician on the phone said he was not known to them and there was no recognition he was at risk,' she said. 'All through the call he was ranting on about mental health services failing him.'
She added: 'Three years ago I called 999 saying I need my son sectioned. He was screaming down the phone saying he was going to kill himself.'
'He wanted answers on why he felt the way he did,' added Mr Murdoch. 'Everything was so slow. Ultimately I do not think mental health teams did enough.'
John was described as a 'selfless' and 'much loved big character'.
'He was one of those people who was intelligently brilliant and superb with his hands,' said Mr Murdoch.
Lessons learned
After the inquest IC24, which provides the NHS 111 service, said lessons have been learned from John's death.
A report presented to the coroner said the service will be putting in place 'robust and specific training around perceived abusive or aggressive patients'.
They will also 'improve cross service working to ensure 111 has access to mental health services so patients expressing suicidal behaviours receive adequate safeguarding and referrals.'
Andrew Catto, Chief Medical Officer at IC24, said: 'Firstly, we would like to again express our deepest sympathies to Mr Worthington's family. Following his death a full investigation was carried out into his contact with our service to identify any learning.
'As a result a number of opportunities were identified, including enhanced partnership and information sharing with other healthcare providers to support our patients.'
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