The family of a young man who committed suicide at a Derbyshire beauty spot say he should have been admitted into a mental health facility when he said he wanted to be.
An inquest heard Tom Bradshaw met with medics in January and expressed a desire to go into the Hartington Unit in Chesterfield - three days before he killed himself.
Tom was a good lad. I never had a bad word to say about himRyan Whittaker
Despite his request, the 25-year-old – who attended the consultation at Chesterfield Royal Hospital with marks around his neck from a previous suicide attempt and made a threat to harm himself and others – agreed to a plan for community-based care.
The body of Mr Bradshaw, who had a history of depression and dyslexia, was found in Poolsbrook Country Park.
During Wednesday’s highly emotional inquest at Chesterfield coroners’ court, Mr Bradshaw’s brother Ben said: “Tom should have been admitted (to the Hartington Unit) when he went to the hospital.
“They shouldn’t have let him walk out that day.”
Ryan Whittaker, who grew up with Mr Bradshaw, paid a touching tribute to his close friend.
He said: “Tom was a good lad.
“I never had a bad word to say about him.
“If you needed Tom, he’d be there.”
Mr Whittaker told the court Mr Bradshaw was sectioned last December after he took an overdose and he tried to hang himself on January 21.
He explained Mr Bradshaw – who lived with him – was low after his relationship broke down and he was denied access to his children.
Mr Whittaker said: “After he tried to hang himself, I said to him ‘we’ve got to sort this out. It’s not fair for you and it’s not fair for the people who love you’.
“He cried and hugged me and I said it was time to take him to Chesterfield Royal Hospital and he agreed.”
At the hospital, Mr Bradshaw underwent a one-hour assessment with a specialist nurse and a consultant psychiatrist.
Mr Whittaker, who was in attendance at the consultation, told the inquest: “He felt he needed to be somewhere where he could be watched.
“He expressed he wanted to be admitted.
“I said I felt he needed to be observed for his own safety.
“He was crying out for help because he knew he had the capabilities to harm himself and I think that scared him.
“Tom got handed phone numbers to ring when he needed someone to talk to – but he wasn’t the type of guy who’d call a random person and talk about his problems.”
Mr Whittaker added: “After the assessment, we said to each other ‘that was proper bulls**t’.
“I told him I was always there for him and we went to have a few beers to take our minds off the events of that day.”
Referring to three days later, January 24, Mr Whittaker said: “Tom grabbed my hand and said ‘you’ve been like a brother to me – but please don’t follow me’.
“He kissed my hand and walked away.
“I tried to find him but I couldn’t.
“Later, a friend contacted me about an air ambulance at Poolsbrook.
“I just knew it was Tom.”
Coroner James Newman publicly praised Mr Whittaker, saying: “You managed to get Tom to hospital to seek assistance and I express my gratitude to you.”
Specialist nurse Clare Gerrard told the court Mr Bradshaw ‘didn’t express an immediate attempt to self-harm’ at the time of the consultation.
She said Mr Bradshaw had marks on his neck from the earlier suicide attempt.
Mrs Gerrard added: “We offered him information about what support and information was available.”
Consultant psychiatrist Dr Sugato Sarkar said there was a ‘discussion’ with Mr Bradshaw about admission to the Hartington Unit during the assessment.
Dr Sarkar added: “In Tom’s case, he was willing to partake in assessment in the community.
“I didn’t think there was any clinical reason to consider compulsory admission.
“He said ‘if you can help me with access to my children, I’m prepared to work with you’.
“He wasn’t angry, he was engaged.
“He pinpointed his problems and wanted help on a practical level.
“Here was someone who admitted serious self-harm, reflected on it and wanted to take control.”
Family members said Mr Bradshaw could have been putting up a ‘front’ at the assessment to make it seem like he was OK.
However, Dr Sarkar said he did not feel this was the case and added: “At that point in time I felt it was a positive turnaround.”
Dr Sarkar added: “He did say if he had access to a gun he would shoot everyone who made his life miserable and turn it on himself.
“I told him he couldn’t have access to his kids if he made statements like that and he took this on board.”
Mr Bradshaw’s brother Ben shouted out: “They didn’t do their jobs properly.
“This is being heard in the wrong type of court.”
Mr Newman said: “I’d like to remind the court that coroners do not consider matters of civil or criminal liability.
“I don’t have the power to answer all the questions you may have.”
He added: “It was agreed they would attempt to assist Tom.
“There was no legal requirement to admit him.
“Despite a request to be admitted, Tom agreed a management plan for community-based care.”
Mr Newman concluded Mr Bradshaw committed suicide while the balance of his mind was disturbed.
He said: “I find that Tom was in a position from which he could see no successful outcome.”
Mr Newman expressed his condolences to Mr Bradshaw’s loved ones.
• The Samaritans provides a free, confidential listening service all day, every day, all year. Whatever you’re going through, you can call the helpline on 116 123 or email email@example.com. Visit www.samaritans.org.uk for details about the Samaritans. Mind offers information and advice to people suffering from mental health problems. Call the Mind Infoline on 0300 123 3393 or email firstname.lastname@example.org. Visit www.mind.org.uk for more information about Mind. For more information about Dora, visit dora-mentalhealth.org.uk