THE heartbroken family of a teenager who committed suicide after battling a series of mental health problems have hit out at the care he received after an inquest into his death.

Charley Marks, 18, of Burnham-on-Sea and a former student of King Alfred School, died after hanging himself on September 10 after suffering from a number of mental health issues, a coroner ruled.

The two-day inquest, held in Taunton, heard Charley had struggled with issues such as depression, OCD and anxiety, and was in contact with nurses from the NHS’ mental health teams shortly before his death.

The coroner read out statements from Lorriane Waitz and Jaqueline Chedzoy to the inquest, who were both mental health nurses involved with Mr Marks’ care.

The statements detailed how Miss Chedzoy had contact with Mr Marks before he died over the phone due to his discharge from hospital on September 4, six days before his death.

It was organised Mr Marks was to be contacted every day by the mental health team because he was “high risk.”

At the inquest, Dr Turner questioned why no formal log had been made of Mr Marks’ death and why little physical contact had been made with Mr Mark’s before his death.

Miss Chedzoy replied saying she met him in person on 10 September, just hours before his death, but upon doing his notes she had done so retrospectively, even though this was not shown on the system.

She added Mr Marks had informed her he had been having suicidal thoughts, but that he ‘had no concrete plans’ to take his life and the thoughts were only fleeting.

The inquest heard that the NHS had changed its treatment practices regarding mental health services in the area following Mr Marks’ death.

However, in a statement issued to the Weekly News following the inquest, Mr Marks' family hit out at the NHS.

Mr Marks’ grandfather, George Clement, said: “On behalf of the family would like to thank the Coroner for undertaking a thorough investigation regarding Charley’s very sad and premature death.

“We feel that the final verdict that Charley committed suicide after being seen by nursing staff of the Somerset Partnership NHS Trust was significant.

“It was difficult for us to hear some of the evidence given by the nursing and other medical staff who had responsibility for Charley’s care and had carried out assessments of Charley’s mental state a week and then not much more than an hour before Charley took his own life and who only contacted him in the six days after his release from Rydon Ward, twice by telephone and then with a single visit an hour before he died.

“This was clearly a tragic mistake.

“It has come to light that the nurses only spent a very short time with Charley that day and his sad death demonstrates they wrongly concluded that he was not a suicide risk, despite him telling them that he still had thoughts of suicide by violent means, including hanging.

“We were encouraged by the evidence of Mr Jackson who explained to the inquest that significant changes are being made and have been implemented in the care of young people with mental health problems in the Somerset Partnership NHS Trust.

“It is regrettable that it took the death of Charley, a much loved son, brother, grandson and friend to everyone, to force the Somerset NHS Trust to make these considerable changes.

“If these changes prevent further suicides in young people together with the complete devastation of a family that follows then let us all hope and pray that it may be worthwhile.”

Neil Jackson, Somerset Partnership Head of Mental Health Inpatient and Crisis Services, responded to the inquiry and said: “On behalf of the Trust, I want to express our condolences to the family and friends of Charley Marks on their tragic loss. Our thoughts are with them. 

“We join with Charley’s family in thanking the coroner for his thorough investigation into Charley’s death in 2014.

“Immediately after Charley’s death, we conducted a thorough review of Charley’s care and identified some areas of improvement.

"These include making sure a patient’s discharge plan is formally agreed and shared will the patient, their family, and all staff involved in the patient’s care.

"We also make sure, as part of our suicide prevention strategy, any patient with a risk of suicide has a follow up meeting with a member of the community team within 48 hours.

“As the inquest heard, since Charley’s death we have been making a number of important changes to support young people in our mental health services as they become adults.

“We are transforming our services for patients aged 18 years old to ensure a smoother transition from young people’s mental health services to adult services.

"So rather than these patients having to move to new teams and services when they hit 18, they will get the choice to stay with their existing support so there is no disruption to their care.”

Coroner Tony Williams concluded Mr Marks committed suicide on September 10, by suspension by ligature and died from asphyxiation.