A mother has claimed her son, who had complex needs, was “let down by the system” prior to his death.

Jay, also known as ‘JJ’, suffered from a number of physical and mental health conditions, including childhood autism and borderline personality disorder.

He had disclosed alleged abuse, was known to use illicit substances, and had also self-harmed.

Having moved to Middlesbrough in 2020, the 23-year-old, who had a passion for art and drawing, took his own life in December 2022.

His exact cause of death is still to be determined with a coroner’s inquest yet to be held.

The roles played by various service providers in the six months leading up to his death – including a council, two acute hospital trusts, a mental health trust and the police – were subject to a safeguarding adult rapid review commissioned by the Teeswide Adult Safeguarding Board (TSAB).

A report described how Jay’s mother felt he was “let down by the wider system in that his needs were not fully recognised or understood”.

It outlined how a number of service improvements were planned with a review of cross-boundary working in safeguarding cases being undertaken by Middlesbrough Council, which had received three formal safeguarding concerns in relation to him.

Meanwhile, one of the acute hospital trusts was reviewing its mental health strategy and training available for staff in mental health awareness.

Jay, whose birth name was Tia, later identified himself as a transgender male, something his family accepted.

His mother complained that insufficient information was provided to the family about his conditions and treatment, although it was acknowledged that there were limitations in what could be shared, especially in circumstances where Jay himself did not want disclosure to be made.

It was also felt that the housing he was provided with was inappropriate.

In a statement provided for the review his mother suggested his “cries for help” had not been taken seriously and she had been “locked out” when it came to important medical information.

She said: “There are many questions that I have that I don’t yet have the answers to. 

“I visit Jay frequently at the cemetery to refresh the flowers and clean the headstone as it’s the only thing I can do to care for my child who is now gone. “

She added: “Underneath that hard, stubborn exterior was a caring person who made people laugh with his humour and wit. 

“His early career goals of being a paramedic and only wanting to help others. 

“We always lived in hope that Jay would heal and start living his life with happiness and a new outlook on the world. 

“The loss to the family has been devastating. 

“We feel so let down by the events that led up to Jay taking his own life.”

Jay, who had been identified as a suicide risk, was said to have been offered support by numerous agencies and was admitted into mental health facilities on 26 occasions between February 2020 and December 2022.

The review found that staff involved in caring for him were responsive to his needs and where possible took his wishes into account, while showing empathy and a caring attitude.

However, across the system, responses varied regarding completion of mental health capacity assessments for Jay. 

Individual agencies confirmed that good practice guidance was not always followed and assessments were not recorded or only partially recorded with the report stating they should be fully recorded in line with policies and procedures.

In addition, some partner agencies were of the view that matters arising from the capacity of an individual did not apply to them, and therefore they had no obligation to assess this.

The report said: “There is strong evidence to suggest that JJ was making decisions which were very harmful and many would argue that they were unwise.”

There was also confusion at times over relevant legislation and his legal status.

The report said legal advice should be sought at the earliest opportunity to avoid any delays in providing care and support to the person concerned, in case of a disagreement between partners.

The report also highlighted the importance of the timely sharing of relevant information between organisations with an “assertive outreach” approach recommended to improve engagement.

It said the nature of the risk to Jay was often “very dynamic and rapidly changing”.

Jay was said to have overdosed and inflicted injuries on himself and as a result in the six months up to December 2022 had attended A&E 58 times.

TSAB is a statutory body which co-ordinates and ensures the effectiveness of work to safeguard adults living in Teesside.

It said the report was an opportunity to “remind partners of their duties of professional challenge and curiosity” and to seek assurance from them that adequate training is provided to staff.

Local authorities and housing providers were also being asked to provide assurance statements on the provision of appropriate accommodation for service users.

At one stage Jay had been made homeless following a breakdown in his tenancy at supported accommodation which saw him served notice to leave.

Adrian Green, independent chairman of TSAB, said: “This is a sad and highly complex case – our thoughts are with JJ’s family and friends and we are deeply sorry for their loss.

“The review has identified that a number of agencies and individuals were aware of the issues and challenges facing JJ. 

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“It also highlights the work they undertook, both individually and collaboratively, to offer him the help and support he so clearly needed.

“The review contains a number of constructive recommendations that will help to improve practice and the way agencies work together in the future.

“The safeguarding adults board is committed to implementing these recommendations and will keep progress under review.”