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A devastated step-dad has called for "big changes" to the way mental health services are delivered as he feels his son failed to get the support he needed.
Elliott Holmes, from Istead Rise, Gravesend, took his own life in June aged just 19.
The teenager had a history of mental health issues including OCD, depression, self harming and suicidal thoughts, an inquest heard.
At today's hearing held at The Shepway Centre, Maidstone, assistant coroner Alan Blunsdon was told Elliott was discovered by police close to the family home in The Droveway, Istead Rise.
Elliott, who had been training as an apprentice engineer, had ventured off alone into the woods with a backpack and alcohol, when his step-dad Peter Scutts sounded the alarm.
Before Elliott took his own life he had posted a Snapchat video which showed his surroundings but it was not immediately possible to identify his precise location.
Shortly after, officers found him unresponsive near a pylon with suicide letters tucked in his waistband intended for family and friends.
At the inquest, evidence was heard from medical professionals Elliott had come into contact with – through a mix of some face-to-face meets and telephone calls – in the months leading up to his death.
On January 6, Elliott was referred to the Kent and Medway NHS Partnership Trust (KMPT) from his GP after experiencing "auditory hallucinations" and "intrusive thoughts".
He was prescribed a starter course of an anti-depressant, and a letter in February recommended he explore talking therapies.
But the coroner heard there were some "hiccups" and "gaps in the care plan" offered to Elliott.
This included a finding that the Single Point of Access 24/7 helpline, which manages all adult mental health referrals, had mismanaged a call from Elliott's step-dad a week before his death.
Mr Scutts had requested a callback on June 17, a week before Elliott died, saying his son had tried to take his own life two days prior.
But the operator explained Elliott would have to call and refer himself, that a clinician would call within 72 hours and assess his situation and that if they had any worries they should call the police.
At the inquest it was admitted this was not the correct procedure and that "risk outweighs consent" and should have necessitated a different response given the patient's history.
Noting a similar incident before the court from December, assistant coroner Alan Blunsdon requested anonymised monthly audits – which have been introduced since Elliott's death – be provided to ensure the procedure is correctly followed in future.
Recording a verdict of death by suspension, he said: "It is in my view it was probably unlikely that steps could have been taken to prevent Elliott from undertaking something he had clearly intended to do.
"My conclusion is that Elliott did intend to, and did by his own hand, end his own life.
"I extend my sympathies to Mr Scutts and offer his family my condolences."
Speaking on behalf of the family after the inquest's conclusion, Mr Scutts said he believed the support they received was substandard.
He said: "Elliott was a troubled soul. From an early age we knew Elliott needed professional help and reached out to the mental health services some nine years ago.
"Elliott's hearing voices, depression and suicidal thoughts are well documented in the reports, but sadly no sign of any talking therapy being delivered in nine years, no single person to build trust with – merely medication subscribed to subdue the effects.
"We are not looking to blame anyone for Elliott's death, but we feel the support received from the mental health services sadly lacked in any real substance."
The Gravesend businessman added what they felt were failings over Elliott's final months had been evident and described the never-ending "merry-go-round" of triaging, referrals and assessments.
"Even someone who had recently been documented as suicidal; tried to take their life two days prior isn't considered for an outbound call," he said.
'We cannot bring Elliott back, we can only look to the future..."
Mr Scutts said problems worsened after Elliott turned 18 and was therefore deemed an adult in the eyes of the institutions helping him.
He claimed the system was "not in touch" with the reality of people asking for help and needs changing.
"The therapists who are so badly needed are buried so deep behind layers of bureaucracy, only the chosen few will ever have the privilege to access them," he added.
"I appreciate the system is overloaded with demand, I accept people are trying their best but the system needs a thorough overhaul.
"We need a system that is fit for purpose, a system that takes ownership, a system that puts users directly in the front of therapists at the earliest of opportunity instead of letting these problems fester for years, to the point where patients like Elliott become a lost cause."
Moving forward he hopes lessons can be learnt from Elliott's death so that other families will not have to endure the pain himself and his wife, Elliott's mum Kerry, have suffered.
"We cannot bring Elliott back, we can only look to the future," said Mr Scutts.
"We all need to make sure that Elliott's life, along with the other 30 or so teenagers in Kent who have committed suicide this year, are not in vain and this is a platform for change – big change."
A statement from Kent and Medway NHS and Social Care Partnership Trust said: “We are truly saddened by Elliott’s death and our thoughts are with Elliott’s family and all who loved him.
“Following our own investigations, we have put in place a clear audit process for calls to our Single Point of Access Service which was recognised by Her Majesty’s Coroner. We will continue to work with Her Majesty’s Corner’s Court in an open and transparent way to show the changes we have made are truly embedded.
“We would, as always, be happy to talk with Elliott’s family about any questions they might have about his care.”
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