'We were abandoned', says mother of man who killed himself
In January 2013, 25-year-old Chris Wood, from Cardiff, killed himself.
He had been suffering from mental health problems for several years.
An independent report says his death could have been prevented had he received the care he needed.
Here, his mother talks about life with her 'lovely son' and her family's fight to find out why more was not done to help him.
Debbie Wood spends her Saturday nights reliving the horror of 26 January 2013 - the night her youngest son Chris died.
She agonises about how things might have been different had she picked up the phone and spoken to him.
But social workers had advised her not to text and call him too often when he was out, so she resisted the urge.
It is a decision she says she will always regret.
When she did call, it was too late.
"He was a really lovely person. He was very gentle and kind and he was a perfect son," Mrs Wood recalls.
"When he was well he was very happy. As a little boy he was always so happy we used to call him our little sunshine.
"You can see in photos he was always smiling. He loved sports, music, going to the cinema and he was very close to other family members."
But Chris had complex mental health problems.
He had borderline personality disorder and made 32 attempts to end his life.
Mrs Wood first began to realise something was wrong when Chris was a teenager and became withdrawn and isolated from his friends.
"The first problem was about eight years ago when he took his first overdose," she says.
"That was closely followed by another and he was taken into the care of the community mental health team."
Life with Chris quickly became chaotic.
"He could be in the house and he would suddenly just run out and you'd go after him and have to try to find him and bring him back.
"Sometimes he would be found on the top of a bridge.
"Other times he'd overdose or he'd harm himself in some other way.
"He didn't seem to be able to control how he was feeling.
"We found that if he was taken into hospital, even if it was just a brief period, that would seem to diffuse the situation and when he'd come out, he would seem a lot better."
There was confusion about Chris's diagnosis - first the family was told he had dissociative disorder, later they were told it was borderline personality disorder.
"We didn't really have information and we weren't really aware of what was going on, we didn't really fully understand the situation."
Chris had regular appointments with healthcare professionals in Cardiff but Mrs Wood says they were often a cause of huge frustration.
"Chris was being told that he was fine.
"We were becoming increasingly dismayed as time went by that nothing more seemed to be done for him."
Requests for more help and advice on how to deal with Chris's problems fell on deaf ears, Mrs Wood claims.
"We also asked for someone to chase up an urgent appointment we were waiting on to assess Chris's risk to himself - we thought that was of paramount importance but we couldn't seem to get anyone to chase this up, no matter how hard we tried."
A report commissioned by Cardiff and Vale University Health Board and Mrs Wood's solicitor found that the failings in care arose because of the lack of a care coordinator and specific interventions for his complex problems.
To make matters worse, Chris also suffered from fits.
In 2010, he was diagnosed with epilepsy but, after further tests, his consultant psychiatrist, Dr Sudad Jawad, reversed the diagnosis.
Chris remained on the medication for epilepsy but continued to have fits.
"It made a terrible situation even worse," adds Mrs Wood. "We were completely confused about the whole thing.
"In the last months of his life, he had 12 fits in 20 days.
"At that point he was even too scared to sleep.
"We said everything we could to try and get help for him and there was no response."
Mrs Wood has raised questions about the care received from Dr Jawad, who treated Chris from 2008 until he died.
Dr Jawad has since retired and Mrs Wood's complaints are being investigated by the GMC.
Dr Jawad said it would be inappropriate for him to comment while that investigation is ongoing.
Despite his mental health issues, Chris did his best to live an independent life.
He had worked in a local pub and was training to be the assistant manager but had to leave when his problems became more acute.
He also started an IT college course.
"His brother always says he was very brave," says Mrs Wood.
"Even during the period with all these fits he did manage to keep going and he did quite well, all things considered, in his work life before that."
She believes that things could have been very different for him had he had better care and more of an understanding of borderline personality disorder.
"We knew very little at the time.
"We were just told to look it up on the internet.
"People with borderline personality disorders like Chris can be very impulsive and can't manage their emotions in the way that you and I would if anything goes wrong.
"He found it very difficult to cope with life and relationships were quite difficult for him to maintain."
In 2012, things took a turn for the worse for Chris and his family.
Doctors decided that admitting Chris to hospital was making his condition worse in the long run, so they resolved to try to avoid hospitalisation when possible.
His family say they were not informed of this decision.
"We couldn't understand why there was no response because once again we weren't really aware of the circumstances - even though we were the only ones who were actually caring for Chris in the community.
"We didn't really have anyone else to turn to.
"Somehow we just coped as best we could. What choice did we have?"
Keeping an eye on Chris was a full-time job.
Away from home, he would often text his mother and she could gauge how he was feeling.
"We'd text him and if he texted back, we'd think oh he's fine, everything's OK.
"If we didn't hear anything, then I'd text him again after a while and sometimes it was fine, other times there would be no response and then you would ring and if there was no answer then we got to know that it was likely there was a problem.
"In the early days he would quite often text me and say 'Goodbye, I'm sorry, I love you, it's nobody's fault' and then he'd switch his phone off and disappear. Obviously, we'd be panic stricken."
Chris's family got to know the places he would be likely to go.
"Sometimes we'd get there and you'd find the police were there, they'd found him on the wrong side of the barrier on a bridge.
"Sometimes we'd get a phone call and he'd been found on top of a building somewhere."
Even at home it was difficult for his family to ensure his safety.
"There was one occasion where we were in the living room and all the lights went out.
"The next thing we knew, there's banging on the front door and it's the police.
"Chris's friend had been murdered and he couldn't cope with it so he tried to electrocute himself.
"He'd warned the police about what he was going to do so we didn't find him."
Despite repeated suicide attempts, Chris's care did not seem to improve.
It was like firefighting, says Mrs Wood.
"If a proper care plan had been put in place in the beginning it would never have escalated like this and you can see how things got worse.
"I just feel he was let down so badly and so were we.
"We were abandoned, there was no one for us to turn to for advice or help because every time we asked, there was no response."
On the day he died, Chris had seemed quite upbeat and had arranged to meet some friends at the pub where he had worked.
He had arranged for his mother to pick him up at 20:00 GMT but called to say he was going to stay later.
"I listened to the background - it was bubbly and it sounded very positive so we said ok," says Mrs Wood.
"I texted him at 9.20pm and asked how it was, he said that everything was fine and that he'd be home a bit later.
"It got to about 10.15pm and because of our previous experiences, I was anxious and really all I wanted to do was ring him and say 'Look, where are you?'
"But we'd had an assessment from a social worker who'd said that it was best not to text him too much in case it stressed him out.
"I didn't want to appear not to be taking on board things that they said to us and that's something I'll always regret."
When she eventually called, there was no response so Mrs Wood and her husband Robin went to look for their son.
They found him in a lane in Cardiff.
"At first, I thought we'd arrived in time, we'd found him, he was fine.
"We pulled into the lane, then I realised what he'd done - he'd hanged himself on the gates.
"We went to the hospital and eventually they came and told us that they'd tried but there was nothing more they could do.
"I just couldn't believe it. We had taken him to A&E so many times - and always brought him back with us - that there was a big part of me that really couldn't believe it."
Life has never been the same for Mrs Wood and the family.
"It's hell, it really is.
"Somehow you have to find a way through every day.
"I focus on trying to get something done about what happened to my son because it was just disgraceful the way he was treated.
Cardiff and Vale University Health Board has apologised and said that the findings of its report into Chris's death have been recognised and accepted.
A spokesperson said that changes had been made to help prevent this happening again.
But Mrs Wood is still concerned for others in similar situations.
"If nobody speaks out, then this will continue to happen.
"I'm hoping that if people actually realised just how bad the care is for vulnerable, young people in society something might actually be done.
"If someone had spoken out before - maybe my son might still be here."