Chris Wood: Son's death 'could have been prevented'
The death of a 25-year-old with borderline personality disorder could have been prevented, an independent report seen by BBC Wales has found.
Chris Wood, from Cardiff, killed himself in January 2013.
Charity Hafal said the Welsh Government needed to ensure health boards complied with care planning laws for people with mental ill-health.
Cardiff and Vale health board has apologised and said the findings had been recognised and accepted.
A Welsh Government spokesperson said it wanted to "see an end to inconsistency in mental health care".
Mr Wood took his first overdose when he was 21 in 2008. He attempted suicide a further 31 times in the four-and-a-half years after that.
An independent report into his death was commissioned by Cardiff and Vale University Health Board and Mr Wood's mother Debbie's solicitor.
It said: "On the balance of probability, had Chris been provided with a reasonable standard of care, including being provided with a care co-ordinator and being provided with specific interventions for the personality problem with which he presented then on the balance of probability, his death would have been prevented."
Mr Wood had regular contact with mental health services from 2008.
The report raised concerns about the Cardiff and Vale University Health Board's care of Mr Wood.
It said: "…that Chris's care plan, such as it was, was inadequate and, in the matter of family involvement, I need to reiterate my grave concern regarding the lack of family involvement."
Mrs Wood feels there was confusion about her son's diagnosis and that life became very difficult as his condition worsened.
"Day-to-day life was as chaotic as his care, to be honest," she said.
"He didn't seem to be able to control how he was feeling and we hadn't really been given any explanation and we were struggling to understand it and to cope with it.
"He would disappear at night and my husband would be out late at night looking for him.
"Sometimes he would be found on the top of a bridge, on high buildings, other times he'd overdose or he'd harm himself in some other way."
The report, written by Prof Kevin Gournay CBE, said: "In the records that I have seen there is no evidence, in my opinion, that the risk of self-harm/suicide was competently and correctly assessed in 2012."
Mrs Wood said the family became increasingly dismayed as time went by.
"We spoke out about how we felt - that he needed more help and we needed more advice on how to deal with it - and in the last few months of Chris's life there were several crises."
Things became worse and on 26 January 2013 Mr Wood hanged himself. He was found by his parents.
'Haunt us forever'
"For my lovely son who we'd fought so hard to keep safe, to die in the street like that, it was just horrendous, it really was," said Mrs Wood.
"If anybody had actually just listened to anything we said and given Chris the appropriate help, this could have all been avoided.
"For us, that is the worst thing and will haunt us forever."
The coroner at Mr Wood's inquest did not find that neglect had contributed to his death.
However, the report was published three years after the inquest and Mrs Wood says it raises questions about the care her son received from Dr Sudad Jawad, who was his consultant psychiatrist from 2008 until his death.
Dr Jawad has since retired and Mrs Wood's complaints are being investigated by the GMC. He said it would be inappropriate for him to comment while the investigation was ongoing.
Hafal chief executive Alun Thomas said: "We hear too much that we've learned lessons from these kinds of cases, enough is enough and if people don't want to deliver to the Mental Health Measure they need to give up delivering the mental health services.
"We have some excellent services in Wales but we also have some very poor services in Wales and if it comes to a single health board improving that, then we'd be all for it."
A Cardiff and Vale University Health Board spokesperson said: "The health board has taken steps to address the issues raised in the independent report and has met with the family regularly and settled the case in line with the legal process.
"We are unable to go into the exact details of this difficult and lengthy legal case but would like to reassure the family and the public that changes have been made in response to the issues raised to mitigate this happening again.
"The health board has further developed the personality disorder service, Cynnwys, to provide better support for people with severe emotional, behavioural and relationship difficulties and the recommendations of the coroner have been implemented in full."
A Welsh Government spokesperson said: "We want to see an end to inconsistency in mental health care.
"We expect services to comply with national guidelines such as NICE and have introduced a Mental Health Measure to ensure that all individuals in secondary services have a care and treatment plan, and can ask for a reassessment if they are discharged.
"Mental health treatment, support and prevention services will be a priority for this government, with greater access to talking therapies at earlier stages in order to help people cope with emotional challenges."