A mother’s concerns over the mental health care given to her 20-year-old son before he committed suicide has triggered action from a Canterbury coroner.

At an inquest into the death of Joshua Brown from Teynham, who plunged to his death from a cliff, coroner Rebecca Cobb ruled that she would be making a report to prevent further deaths.

CCTV captured Joshua climbing over a railing on a cliff edge in Broadstairs before falling to his death, the last of many attempts to take his own life, including downing a toxic mix of limescale remover, bleach and red wine.

The air ambulance was scrambled after a passerby found Joshua near Louisa Bay in April 2011, but he was pronounced dead at the scene.

Known to the mental health team from the age of 13, Joshua suffered from depression and was seen by staff from the Medway Community Mental Health Team on a regular basis up until his death.

But Joshua’s mother Tracey spoke at the inquest about how she felt she should have been included in discussions about Josh’s health and that her concerns were ignored by the team.

She said she had been worried that her son was making jokes to “paper over the cracks of his feelings”, and that these gave a false impression to care workers.

Just days before he committed suicide, he missed two appointments with the team but nobody followed the meetings up, a move Tracey believes was fatal.

She said: “Nobody listened to what I was telling them. If they had chosen to discuss it with me, I had a completely different stance on the story.

“Josh told me that he was going to try again to take his own life, but he told the team that he wouldn’t do it again – he was contradicting himself.

“He was one very confused man trying to figure out why he felt the way he was feeling.”

“I should have had some sort of say because I was with him every day. I find it completely distressing that the fact I lived with him was not taken into consideration.”

“I was near to having a mental breakdown because of the lack of support I was getting.”

Lead nurse Andrew Dickers spoke at the inquest and outlined changes the trust had made since Joshua’s case.

He said that previously the trust “didn’t have clear and accurate care plans in our access teams” and that there was no clear plan of “who was doing what” or “what to do if things got difficult.”

He said: “We have brought in a complete assessment, care plan, review of care, care coordination, reviewed risk assessment, reviewed crisis plans and we have reviewed the Do Not Attend policy which gives lessons for staff if their patient does not attend an appointment and they must always follow up.”

Miss Cobb will now make a report for a regulation 28 order.

“I do have concerns that perhaps even within this trust, there may still be areas of lack of engagement" - coroner Rebecca Cobb

This means that she will write to the Care Quality Commissioner, the Department of Health and other health officials to reduce the risk of other deaths occurring in similar circumstances.

She said: “It seems to me that the person who has decided that they don’t want that help is not really in the best position to decide that.”

“I do have concerns that perhaps even within this trust, there may still be areas of lack of engagement.

"Either with family members where a service user does not want information passed on or lack of an ability to engage with the mental health team.”

Miss Cobb recorded the cause of death as suicide while suffering from depression.