Creaton couple say mental health system let their son down

The family of a man who killed himself while waiting for an ambulance say he would still be alive if public mental health care had been better.

Liam McCarlie, 35, from Creaton, Northamptonshire, was under the care of Northamptonshire Healthcare Foundation Trust’s (NHFT) mental health team when he died on 1 April 2023.

His father and stepmother said that they and their son believed that this system would help him, but they felt that opportunities were being missed and changes were needed to monitor the patient.

The trust said new measures to support vulnerable mental health patients had been introduced.

Last year, while on holiday in Scotland, Doug and Lanor McCarlie became concerned about Liam after receiving disturbing text messages and phone calls.

Standing 600 miles (965km) away, they called 999 for an ambulance.

Mr McCarlie said: “He was giving signs that he was going to kill himself. We thought ‘We can’t mess up here.’

It took more than five hours for the ambulance to arrive.

However, Mr McCarlie said his family did not blame the ambulance service.

“If only the mental health team had done a better job, we wouldn’t have needed an ambulance that night,” he said.

“Even 15 months later, we’re still dealing with the grief every day.”

The NHFT was not given any recommendations in his report.

Liam’s mental health began to deteriorate in 2021 following the death of his grandmother, who was his “absolute rock”, his parents said.

He had many tragic events since then.

Mrs McCarlie said: “Six months after her child’s death, she tried to take her own life and was rehabilitated twice, that’s when we realized the support wasn’t there.

He spent one night in the hospital and was cleared to go home.

“We pushed hard to get him a three-day crisis bed. He’s been under the community mental health team ever since.”

The couple described him as “quiet, kind, thoughtful, caring, shy and patient”.

An avid fisherman and nature photographer, his dog Cleo was “his whole world”, they said.

He had been diagnosed with ADHD and was awaiting diagnosis for an emotionally unstable personality disorder at the time of his death.

While he was waiting, he was taken off all his medication and Ms McCarlie said there was no evidence the mental health team had met him.

A week before her death, her doctor made a quick visit after her family struggled to get help for her deteriorating mental health.

“I called the community mental health team before that and said ‘Where can I bring him? I need to bring him now,'” Ms McCarlie said.

“I think he wasn’t in a good place and we realized we were out of our depth.”

During a call with the urgent care and assessment team (UCAT), the urgency of his delivery was reduced and he was given a posthumous Tuesday appointment.

“We feel that was a completely missed opportunity,” he said.

“We are not in a position to say what should have been done but it is clear that he should not have been left.”

Mr and Mrs McCarlie say they feel they have failed in a way they believe will help them.

“Never in our wildest dreams did we think an ambulance would take five hours,” Mrs McCarlie said.

“We were hoping he wouldn’t stop answering [to messages] that’s because he was in the hospital or on the way.

“When we got the call from the paramedics, we knew.”

Mr McCarlie said: “We believe in the system. We go to work, we pay our taxes and we believe the system is there to protect you and help you when you need it.

“But that’s not our reality.

“We didn’t know he was being demoted because we had faith that the system was working.”

They say changes are needed to prevent patients from falling through gaps in care.

They want case managers to be appointed for each patient, to “monitor” all communication with services and escalate issues as needed.

NHFT says this is already in place.

Liam’s father also said that there should have been a maintenance program for his family to help them support their son.

“Fortunately, we are both very strong mentally, but emotionally, our batteries were very low all the time,” he said.

Liam’s family are hoping to turn his nature photos into cards that can be sold to raise money for mental health aid.

Adam Smith, director of mental health for the NHFT, said the trust had met with the coroner to resolve issues during the inquest.

“As part of our ongoing commitment to developing our services we have recently introduced a number of new initiatives to improve care and support for people with mental health problems , including a new mental health crisis response center that works in conjunction with the ambulance service and a new mental health messaging service,” he said.

He added that all UCAT tests are conducted in person, and guidance has been issued on the importance of communicating with family members and carers.

Staff training also emphasized “the importance of completing risk assessments, a clear safety plan and protecting the transmission,” he said.