“Obvious failings” in care of “likable but troubled” Wymondham man Kai Mayes
- Credit: Chantelle Blanchflower
On March 22 Richard Mayes had travelled to the Queen Elizabeth Hospital and agreed to turn off the life support for one son.
When he returned home he found his youngest son had hanged himself in their workshop at Rockland St Peter, Wymondham.
Kai Mayes' previous suicide attempts had not been acted upon, and at the inquest of the 32-year-old his father said there had been 'obvious failings' in his care.
With a history of drug use for eight years, Mr Mayes' relationship had broken down and he was facing the prospect of custody.
In February he told the Norfolk Recovery Partnership if he wasn't sent to prison he would turn his life around.
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The day before his death the probation service agreed to offer drug rehabilitation as an alternative to custody, but Mr Mayes was never told.
'That could have made all the difference,' said his sister Chantelle Blanchflower.
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His father told Norfolk Coroner's Court: 'Kai had not said anything to me about wanting to harm himself. I could see the court case was weighing heavily on his mind and with each day it became more traumatic for him.'
On the evening before his death Kai had told his sister he wanted to 'get a rope and hang himself'. Despite two previous suicide attempts, an investigation report from Norfolk Recovery Partnership (NRP) found they had not been recorded on risk assessments.
Dr Shaun Conway and Dr Andrew Thompson of the Hingham Surgery wrote in a joint letter Kai was a 'likeable but troubled young man'.
'He was always keen to ask for help to address his addictions when he came to see us. He had not been diagnosed with any specific mental health condition. At his last primary care contact his risk of suicide or self harm was not assessed as he had been asked to attend by NRP. At his most recent assessment from an NRP psychiatrist they noted he was not suicidal.'
Older brother Richard Mayes said Kai was 'a bubbly man with a thrill seeker attitude'.
'This faded towards the end. When he reached driving age he spent a lot of time in Wymondham with a crowd we all knew used hard drugs. We were aware Kai had begun using these drugs but he was a complete master of disguise and kept up a facade of a completely normal life.'
Senior coroner Jacquline Lake recorded a narrative conclusion and wrote to the GP and NRP to ensure changes have been made.
The Samaritans are available 24/7 on 116 123.
Mrs Lake said the NRP investigation report after Mr Mayes' death 'recognised failings'.
They included: 'Drug and alcohol service not being aware of the break down of the relationship with his partner until after his death. Despite Kai having a history of deliberate self harm and suicide attempts, these were not appropriately recorded on risk assessments.'
After the inquest, Richard Mayes said there had been 'obvious failings since 2002'.
'Since we first visited the GP there was a catalogue of reports being unidentified,' he said 'We are responsible because we did not recognise it but medical professionals didn't either, or didn't act on it when it was obvious.
'With several obvious attempts on his life NRP and his own GP, and most of all us sitting in front of you now, didn't really act as we should have done. Maybe this could stop happening to people in the future if the systems are tightened up.'
Bohdan Solomka, Norfolk and Suffolk Foundation Trust's Medical Director, said in a statement: 'We sympathise deeply with the family for their tragic loss and would like to express our sincerest condolences.
'We take the death of one of our service users very seriously and a thorough investigation has been carried out at our Trust, which has highlighted some points of learning.
'These include improved access to service user notes between Norfolk Recovery Partnership and NSFT, which helps us to carry out holistic assessments and manage a service user's risk. All staff across the partnership carry out mandatory suicide prevention and risk assessment training, and we are working closely with GPs and our partner agencies to improve methods of communication.
'The Trust has made contact with the service user's family and are happy to meet with them should they wish to discuss any concerns.'