“I felt so alone. I was desperate for help.”
That was the tearful statement from a mother who has blamed the lack of resource at West Berkshire’s mental health service for the death of her son.
A catalogue of errors leading up to the death of 23-year-old Charlie Whitehouse emerged during the inquest into his death at Berkshire Coroner’s Court in Reading on Monday.
The health service said it was down to “being busy” and having “staffing issues”.
Candice Whitehouse found out her son had died three days after he had gone missing from Bramlings House in August last year.
Bramlings House is a supported accommodation home run by A2 Dominion on behalf of West Berkshire Council in Newbury.
But it does not have trained social workers or mental health care professionals in its support teams, and its arrangement with the council does not specify it.
Ms Whitehouse found out her only son had died after a Thames Valley Police press appeal for information to identify a young man.
“It is abundantly clear to me that Bramlings House neglected their duty of care of my son Charlie,” she said after the hearing.
"He was failed on numerous occasions with the support he needed whilst suffering a mental health crisis.
“I am totally devastated and heartbroken. Bramlings only informed me Charlie was missing three days after he disappeared.
“It was finally confirmed to me by seeing an appeal by Thames Valley Police on Newbury Today’s Facebook page of an unidentified body found in Thatcham.
“I broke down when I saw the picture of his bicycle and description of his tattoo."
The inquest heard Charlie Whitehouse, who was 23, died after standing in front of a train at Thatcham.
The deputy coroner Justine Spencer made a point of saying additional suffering had been caused to the family because of the late implementation of the missing persons protocol.
But recording a verdict of suicide, she said she was satisfied that changes had been made by both A2 Dominion and the West Berkshire mental health service to prevent such failings in the future.
She ruled that while the processes had caused considerable suffering to the family, they had not contributed to his suicide.
Maureen Rawson, the witness for the Berkshire Healthcare NHS Foundation Trust, herself a mental health nurse, told the hearing of significant failings in his care.
The coroner’s inquest is a court, but it is not a court to apportion blame.
But the coroner unusually allowed Ms Whitehouse, supported by members of her family, to question both the health trust and the home to gather more facts about the case.
“It is disappointing that communication between the health services and family was not better,” said the coroner. “This caused significant upset to the family.”
David Birley, the operations manager of the home at Bramlings House for vulnerable young people, also told the coroner that staff had been disciplined for not escalating concerns over his behaviour.
They hadn’t acted on seeing graffiti in his flat, which would have demonstrated a deterioration in his mental health, the inquest heard.
He also said the organisation had now tightened up procedures around instigation of missing persons, after saying that Charlie’s disappearance had not been reported for three days after he was last seen.
He told the inquest that Charlie was allowed to come and go as he pleased, and that his disappearance for a day or two was not out of character.
But Charlie’s mother broke down in tears at the hearing, saying her daily pleas to get more help for her son fell on deaf ears.
The inquest heard that he had struggled with mental health issues for 10 years, and that in the months and weeks before his death from multiple injuries, his condition, which included regular psychotic episodes, had worsened.
“There was a lack of contact - I was calling every day,” Ms Whitehouse told the coroner.
“I felt very alone doing it all alone. It was so hard and I was desperate for help. Charlie had lost hope.
“I would ring up and not get call backs and it was down to my own knowledge as to how bad things were getting.
“He was my only child. I did my best by him but he needed more support when he needed it.”
She addressed the mental health service witness, nurse Ms Rawson, saying: “I could have given you a lot more information about how he was spiralling.
“It was me that stayed with him at Bramlings. I was constantly with him and keeping him safe.
“Having a team behind me would have been amazing. There were occasions when people from mental health services would come out - but just for five or ten minutes and no follow up.
“I’d like to know that things are being changed."
Ms Rawson told the coroner that an internal inquiry after Charlie’s death had unearthed some significant failings.
She said a review was ordered to learn from the mistakes made.
"Considering the contact the mother had with the service further contact should have been made with her,” she said.
She told the court there was a lack of follow up by the duty team when family members had called about their concerns and a lack of follow up from the community mental health team, and missed opportunities to share risk assessments of Charlie’s condition with other care providers.
“Admin error was blamed for some of it,” she said.
“… and we have reviewed operating procedures now so anyone who misses more than three sessions is followed up.”
She said staffing issues with annual leave and reduced capacity in the team had also played a part and that the team was now improving communications with carers to involve them in risk assessments and safety plans.
The court heard that Charlie, who had been having psychotic episodes after “experimenting with drugs” in his teens, was considered relatively stable in 2023, but was reluctant to take more medication as he felt it didn’t help and had side effects.
In the weeks before he died, he had refused to engage with mental health professionals and had become increasingly erratic in his behaviour.
But appraisals of him said he was not presenting as psychotic and he was able to make his own decisions.
Summing up, the coroner said Charlie had the love, care and support of his family - but that he had previously intended to end his own life and he placed himself in the path of the train having been deemed capable of making his own decisions.
“My sincere condolences to his family and friends,” she added.
After the hearing, Jude Cross, director of specialist housing at A2Dominion, said: “We accept the verdict of the coroner and would like to offer our deepest condolences to the family at this difficult time.
“We will continue to do everything we can to support those affected by this tragic incident, and have put in place increased safeguarding measures at our specialist housing schemes."
