A “gentle giant” was let down by mental health services in the lead-up to his death, an inquest has heard.

Kent’ssenior coroner ruled there were a number of “missed opportunities” for professionals to reach out to Ben Hart before he took his own life at his mother’s house near Dover.

The "kind and compassionate" former retail assistant had been in the care of the Kent and Medway NHS and Social Care Partnership Trust (KMPT) at the time of his death.

But chronic understaffing meant the 25-year-old was unable to access the help he required, the inquest heard.

Now, his mother Anna Kerley says she hopes a Prevention of Future Deaths report submitted by senior coroner Patricia Harding will “stop any other families going through what we have gone through”.

Ms Harding has warned that there is a "particularly serious" shortfall in mental health staff in the Dover and Deal area - and there is a risk more lives will be lost if action is not taken.

The inquest at County Hall, Maidstone, heard Ms Kerley found her son dead at their family home in Shepherdswell when she returned from work on the evening of October 13. A subsequent post-mortem gave his cause of death as suspension.

The inquest heard that 10 months earlier, in December 2021, Ben had tried to take his own life and ended up in a coma for three days.

Following this incident, he was placed with a new care coordinator for ongoing care for a number of issues - including PTSD, general anxiety, and enduring personality change after a catastrophic life experience. His previous social worker had gone on maternity leave.

However, his relationship with his new coordinator began to unravel after several periods of not being contacted by the trust – sometimes for months at a time. There was also a referral for a test for autism spectrum disorder (ASD) that was requested in February 2022, and not acted upon until September.

Representatives of KMPT said that Ben's new care coordinator was unable to fulfil his care plan – which involved a visit once a month, to increase to once a week if new medication was issued. They said staffing issues had left her having to carry out multiple roles at the trust.

The shortages were so severe that at the time of Ben’s death, KMPT – which was said to normally operate with 16 full-time nurses – only had eight employed, with two on long-term sick leave.

Due to these issues, there were periods of as long as two months where no mental health professional from the trust made contact with Ben. This included a gap from June 27 to September 5, at a time when he should have been seen once a week.

The perceived lack of care resulted in a complete breakdown in Ben’s relationship with his care coordinator, leading him to submit a complaint against her on September 13, 2022.

He would never be contacted by the trust again.

Daniel Lee, locality manager with KMPT, told the inquest that if a request for a change in care coordinator is made, this would be presented at the trust's weekly multi-disciplinary meeting "to enable a team discussion and action the necessary allocation". While he would not expect a "seamless" transition, it should normally have happened within around a week.

However, senior coroner Patricia Harding surmised that the staffing issues led to Ben being "effectively left without a care coordinator" for about a month before his death.

Mr Lee added there had been a “process” to take the case higher and avoid a lengthy wait that had not been followed, which he described as a “missed opportunity”.

Ms Harding went on to explain that on October 10 and 11, Ben had made three calls to the crisis team in the space of 48 hours. The calls – described in court as “with increasing desperation” – all made reference to his “discontent with the [community] service, concerns about his own wellbeing, and – in the later calls certainly – suicidal ideations”.

The crisis team flagged the calls with the community team. Mr Lee told the court that while guidelines give 72 hours to act on such calls, the trust expects it to happen by the next working day. No such action occurred.

Ruling Ben’s death a suicide, the coroner said the treatment of his calls “fell below the trust’s own expectations and presented missed opportunities for care and treatment”.

“The trust’s only communication [with Ben] was when he or his family contacted them – it is understandable why he felt abandoned,” she added, labelling the staffing levels as “clearly unsafe".

“There were missed opportunities to treat him - his referrals for ASD and ADHD were unnecessarily delayed,” she explained.

“This shortfall, although improved slightly, still endures, and they were such that he was not provided with the service he should have been.”

Making a Prevention of Future Deaths report, she said: “Mental health trusts need to be properly staffed in order to be effective.

“An enduring staffing shortfall means they cannot provide the vital role in society that they do. I understand this is a national shortfall, but it is particularly serious in Dover and Deal.

“There is a particular shortfall in that area. The authorities need to know that there is a risk of future deaths and they need to be able to take action in that respect.”

"Even if it saves one life, some good has come out of the most horrific situation..."

Speaking to KentOnlineafter the ruling yesterday afternoon, Ms Kerley said she wanted to make sure “no more lives are lost”.

“Ben and I had been battling to get him the right support for a long time. All of this is for Ben’s voice to be heard, to try and help people to be aware, and to make the changes to stop it happening again,” she said.

“If it even saves one life, some good has come out of the most horrific situation.

“Ben was a big gentle giant, a kind, compassionate person with an amazing sense of humour, who adored his two dogs and his nieces – they kept him going when things were hard.

“We just hope that out of this it doesn’t happen to anyone else. We don’t to end up down the line and find out that things haven’t improved.

“I would like to place on record my thanks to Tracy Carr and the Talk it Out group [based in Deal], who got Ben some counselling and did all they could to help.”

A spokesperson for Kent and Medway NHS and Social Care Partnership Trust said: "We apologise unreservedly to the Hart family for their loss and offer our deepest condolences. We are sincerely sorry.

“The safety of those we care for is our utmost priority and we recognise that we fell short of that on this occasion.

“We have taken action to address the issues found in our own investigations, and raised in HM Coroner’s inquest, to ensure that the required changes are made across the trust.”