A young man who stabbed himself and tried to jump out of a window was discharged from hospital as “low-risk” before taking his own life eight days later, an inquest has heard.

Gabriel Farmer was taken to Margate's QEQM after making the alarming suicide attempts following an overdose at his home in Broadstairs.

But two nurses who assessed the 23-year-old allowed him to go home the next day, leaving his desperate mum feeling as if she was the only person trying to keep her son alive.

He died little more than a week later after deliberately taking fatal levels of cocaine.

Mum Louise Knight says a lack of support from mental health services had made her feel his suicide was inevitable.

“I told them I couldn’t keep him safe,” she said.

“He was sobbing and I said ‘please don’t send him home with me, I can’t keep him safe’.

“They just told me I was his carer, gave me a care pack and sent us home.

“They didn’t contact me again that week and he died, and I knew he was going to die.

“Yes, he had a loving supportive family, but I didn’t have the professional capability to look after a mentally unwell boy who was hellbent on killing himself because he thought he was ruining everyone’s life.”

An inquest into Gabriel’s death was told he had a history of mental health issues and had made six suicide attempts in the nine months prior to the events of May 5 last year.

On that day paramedics were called to his home after he had taken an intentional drug overdose and lost consciousness.

When he came round, he expressed regret his attempt had failed before stabbing himself and trying to throw himself out of his bedroom window.

Paramedics were forced to restrain him and he was taken to the A&E department at the QEQM Hospital.

The following morning, on May 6, he was assessed by Kent and Medway Partnership Trust’s psychiatric liaison team, which deemed him “low-risk” and discharged him.

At the two-day hearing in Maidstone, the two nurses who saw Gabriel - Maria Briscoll and Patricia Longman - admitted their risk assessment was incorrect.

During a tense cross-examination by the family’s legal representative, Miss Longman tearfully explained she had made her judgement based on conversations with Gabriel, who had denied any further thoughts or plans of suicide.

When pressed on whether Gabriel’s history should have been taken into account when assessing his risk of harming himself, Miss Longman, who was an agency nurse at the time, said he had told her he was just tired and wanted to go home to bed.

But just eight days later, on May 14, Gabriel ingested a fatal amount of cocaine after calling a friend and telling him he was unhappy.

Ms Knight found him on the verge of unconsciousness at their home and he was rushed to hospital by ambulance.

Tragically, despite extended resuscitation attempts, Gabriel died of cocaine toxicity the following day.

His mum said: “That Gabriel was never higher than a low risk baffled me - it always baffled me.

“He said to me ‘Mum, I want to die’ and I said ‘I know you do’, and I felt as though I couldn’t help him.

“I just knew that he was going to succeed in taking his life.”

Gabriel’s history of mental health issues and contact with psychiatric services was examined at the inquest, which started on Tuesday at Oakwood House.

It was told there were six occasions between August 2022 and April 2023 that Gabriel had tried to take his own life, including two other overdoses and two attempts to jump from a cliff.

The most recent occurred just weeks before his tragic suicide.

Ms Knight says his struggles stemmed from some traumatic experiences as a child.

It was revealed at the hearing that Gabriel was haunted by his morbid discovery of a dead body at a music festival.

He was also assaulted aged 16 after a prank gone wrong sparked a retaliatory home invasion that saw him chased through his home by a gang and attacked.

The former Chatham House Grammar School pupil, who was doing his GCSEs at the time, jumped from a first-floor window trying to escape.

The inquest was also told that Gabriel had body-image issues, had struggled with anorexia and bulimia in the past and had experimented with steroids.

Ms Knight says he battled with low self-esteem, believing he was “ugly and skinny - even though he was far from that”.

He deleted most of his Instagram posts prior to his death, and posted one last status on Twitter two hours before taking the overdose, saying: “I love you all, sorry.”

Before announcing her conclusion, coroner Catherine Wood said: “We started yesterday by hearing about the young man that Gabriel was and it was clear that he was a kind, funny young man.

“He was clearly quite clever, with those GCSE results and running his own business.

“He was also an image-conscious young man, who often went to the gym, which unfortunately led him to the use of steroids.

“He began to have trouble in around 2016 and saw both his GP and secondary mental health services.

“Gabriel had traumatic experiences that anyone would have found difficult to deal with.”

In examining the contact Gabriel had with KMPT in the lead-up to his death, the coroner highlighted some potential missed opportunities in his care.

In particular, she raised the issue of the inaccurate risk assessment alongside questions over whether Gabriel should have been referred to the crisis team on the day he was discharged, or been issued an urgent appointment.

She continued: “Had an appointment been made earlier would that have made a difference? Would Gabriel have presented differently? I can’t say with any certainty.

“While I do find that there were shortcomings in this case on the behalf of KMPT, I don’t have enough evidence to suggest that it would have made a difference on the balance of probabilities.

“He was known to be impulsive but a conclusion of suicide requires an element of planning.

“I’m satisfied on the balance of probabilities that Gabriel took his own life.”

Following the conclusion, Ms Knight told KentOnline: “The main thing that I wanted from all this, because I will obviously never be able to bring my son back, is to help others going through this.

“I get so many messages from other parents telling me about what they are going through with their own kids and asking me what they can do.

“I just want to work with the trust and the mental health services to work out how we can move forward and make sure no other family has to go through this.

“I just hate the fact that there is another family that is going through this today and I hate that they are not doing enough to prevent that.”

Gabriel’s father, Mark Farmer, from whom Ms Knight is separated, added: “Gabriel was a beautiful gift that sadly has been returned. A brilliant, articulate, and funny young man.

“He had a life full of great expectations in front of him. The suicide epidemic that threatens the UK population should be addressed at the highest level. Gabe will be in our thoughts and hearts forever.”

Following the inquest, a spokesperson from Kent and Medway NHS and Social Care Partnership Trust offered their condolences to Gabriel’s family.

“Tragically, no one will ever know if his death could have been prevented,” they said.

“We worked hard to safeguard Gabriel, while respecting his wishes about how we did so, as caring for a person in the least restrictive setting possible is beneficial for their recovery.

“We always conduct a comprehensive review if a person tragically dies while under our care.

“This identified some areas for improvement, which we have acted on. We have introduced a new suicide prevention approach, and as part of this implemented new risk assessment training for all clinical staff.

“We have also offered more robust guidance to staff who take calls from carers worried about their loved one. We will now carefully consider any further findings from HM Coroner.”

For confidential support on an emotional issue, call Samaritans any time on 116 123.