A teenager who took his own life had been stopped from a suicide attempt a year earlier but had received "nothing more than a flyer" as help from a health trust.
The body of Kai Mogg, of Enterprise Gardens in Costessey, near Norwich, was discovered at a nearby building site at Britannia Way on July 4 last year.
The 18-year-old had been reported missing by his mother that morning and was later discovered by an electrician.
At an inquest into his death, a court heard how Mr Mogg had a history of mental ill health.
In August 2021, officers from Norfolk Police were called after Mr Mogg was found by a member of the public on a bridge over a dual carriageway.
He talked about his struggles with his mental health and said he had ongoing feelings of wanting to take his life.
Before escorting him home, officers discussed what help was available to him.
Mr Mogg was aged 17 at the time.
The incident was reported via the Norfolk Healthy Child Programme, which is overseen by Cambridgeshire Community Services (CCS) NHS Trust.
Weeks later, the service sent Mr Mogg a letter which has been described as “nothing more than a flyer.”
Speaking at a recent inquest held at Norfolk Coroner’s Court, area coroner Samantha Goward said the letter was “a service information/promotion letter”.
She added: “It looks a bit like a flyer.
"My concern is that a teenager looking at this is just going to say, ‘it’s a flyer’. It doesn’t relate to what’s going on.
“By the time this letter was sent it was now some weeks after the incident with the police.
“It makes no reference to the reason that they are writing, which is to explain that it was following the police contact.
“Nor does it make any reference to being able to assist Kai with any mental health difficulties.”
Reading from the letter, Ms Goward said: “The letter referred to being able to ‘offer support and advice on a range of health-related topics such as keeping you fit and well and managing additional needs’.
“To me this letter in no way explained to Kai that there had been a review following his recent mental health difficulties and that support was being offered as a result of this.”
Giving evidence, Debbie Shulver, head of safeguarding at CCS NHS Trust, said the Trust had learned from Mr Mogg’s death.
She added: “We are taking that learning forward to all of our practitioners, to give them the authority to just use [the letter] as a template and to make that a much more personalised approach to writing to a young person and families.
“That’s ongoing in terms of learning and embedding that into our practice.”
Ms Shulver also accepted that there “could and should have been contact with Kai’s GP” after a review by their clinical team
Ms Goward added: “I was pleased to hear evidence that these letters are now being adapted to match the individual’s needs and to make them more personal and relevant to individuals.”
The medical cause of Mr Mogg’s death was given as hanging due to, or as a result of, combined drug use.
A toxicology report stated that recent cocaine use "likely impacted upon Kai’s cognition and decision-making skills.”
Ms Goward gave a brief narrative concluding Mr Mogg “died due to hanging and use of drugs which may have impaired his cognition, so intent is unclear”.
- Do you need support? Samaritans can be contacted 24/7 by calling 116 123. Alternatively, the NHS First Response Service can be reached on 111, selecting option 2.
- To pay tribute to a loved one, email norfolkobituaries@newsquest.co.uk
- To read all obituaries and tributes join the Facebook group Norfolk's Loved & Lost.
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