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The son of serial killers Fred and Rose West felt he had been "abandoned" by health services before he died from complications after taking medication to relieve his "extreme" chronic pain, an inquest heard.
Barry West was the youngest son of the Wests, who abducted, raped and murdered young women before burying them at their Gloucester home, over a period of 20 years.
When aged just seven, he saw his elder sister Heather beaten to death by Fred and Rose. He was taken into care five years after his sister’s death, along with his siblings
The 40-year-old was found slumped over a table by his support worker at supported living accommodation in Maidstone on the morning of August 28. His death sparked internal investigations at Kent County Council (KCC) and an NHS trust.
An inquest, held in Maidstone today, heard that Mr West had a "a complex medical and mental health history", including an opioid addiction and a history of heroin misuse dating back 19 years.
He had also tried to take his own life in 2015 and medical records showed "many overdoses", but did not make clear whether they were suicide attempts.
It emerged he was also suffering from post traumatic stress disorder, disassociation of identity disorder, anxiety and depression, and chronic pain in his shoulder and back.
During the inquest, aspects of the 40-year-old's care were examined. Mr West had been referred to a supported living service at The Beeches, in St Andrew's Road, after leaving mental health hospital, St Martin's in Canterbury, on August 3.
Numerous agencies, including KCC, the Kent and Medway NHS and Social Care Partnership Trust (KMPT), drugs charity Change Grow Live as well as his GP and a private psychiatrist oversaw his wellbeing.
Giving evidence, Nicholas Esson, KCC services manager at the Canterbury Mental Health Team, said Mr West was having difficulty coping with his pain and also with his medication. As a result, he felt he had no quality of life.
In a meeting with his social worker two days before he died, Mr West found it hard to differentiate between the roles of KCC and KMPT, didn't understand the process of a review into his social care needs and "felt he had been abandoned" by the services.
The next day, he "reported he didn't feel supported and he wasn't getting much one to one engagement from the support staff at the residence."
Mr Esson said Mr West's death sparked an internal review, which looked at how they could support people during the pandemic, how KCC works with KMPT and social work training.
He said: "We have looked at how we can stay in touch with people, due to Covid-19 there were significant challenges on how we could support people.... and we can't do face to face work."
He said they could have engaged with Mr West more significantly than by telephone.
'He reported he didn't feel supported...'
He added that he spoke to Mr West's partner four days before the death, which "really highlighted" his "actual distress."
"We could have done that a lot earlier," he said.
He added they are looking at introducing a "tablet device" which enables people to have face-to-face contact.
Similarly, a serious incident review took place at KMPT following the death, with seven recommendations made.
Coroner, Patricia Harding said it didn't appear "there was a round table discussion between all of the professionals dealing" with Mr West and a joint approach to Mr West's care.
Buba Cooper, from KMPT, said one of the recommendations from the review was that professionals dealing with patients with complex needs should have regular meeting, to come up with a plan.
Ms Harding then said she was satisfied that a multi-disciplinary approach was being built into a future care plan.
The inquest heard how Mr West clashed with his doctor over how to handle his chronic pain. He wanted to return an opioid treatment he was given while in rehab in Scotland, where he was the "happiest and pain-free he had ever been."
His doctor, however, said that the treatment would not mix well with the medication he was currently on and she wanted to find a long-term plan to deal with his "extreme" pain, rather than medication, which was a "cul de sac".
'There were many times he was very frustrated...'
She said: "There were many times he was very frustrated at our unwillingness to prescribe an additional opioid and he said life was not worth living."
It also emerged in the inquest that Mr West had told a friend on August 27 that he had been to Canterbury to buy some morphine patches, but no evidence of these were found and it could not be established whether he had purchased any.
Ms Harding ruled death by misadventure and said Mr West had died following "voluntary injections of pain relieving medication."
This caused an acute lung injury known as aspiration pneumonitis and excess fluid in the lungs, which make it difficult to breathe. Shoulder and back pain was given as a contributing factor.
Speaking to KentOnline following Mr West's death last year, journalist Howard Sounes, who wrote a book about the killers, said their son had led "a very difficult and tragic life".
"He was a very complicated unhappy person," Mr Sounes said. "I spent a lot of time with him and he was very badly damaged.
"He was 40 when he died but he didn’t seem like a 40-year-old, it was like talking to a much younger, immature person."
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