Failings from a mental health trust and a GP contributed to the death of a 21-year-old man "with huge potential", a coroner has said.

An inquest into the death of Emmett Gillah heard the Tunbridge Wells resident suffered from a history of mental health problems dating back to November 2014 after suffering an assault.

The attack left Mr Gillah suffering with paranoia and delusional behaviour, the inquest heard.

Despite his background, evidence given at the inquest suggested Kent and Medway NHS and Social Care Care Partnership Trust discharged Mr Gillah from his community care team too early and without adequate support after he was released.

He was released in April 2015 and died after he was hit by a train at Nutfield train station in Surrey in January 2016.

His mother, Wendy Gillah, said: "My son was a loving, creative, intelligent and warm hearted young man with huge potential but he was also very ill, and had been for many months.

"We relied on professionals to support Emmett and to keep him safe, yet he was allowed to drift and deteriorate without anyone identifying how poorly he was or taking steps to help him and stop him from harming himself."

Following a five day inquest, assistant coroner Darren Stewart ruled Mr Gillah's death was by misadventure, adding his mental health was a contributing factor.

Chris Callender of Simpson Millar, said: "Despite his mother’s desperate efforts to get help through his GP and to prevent him from self-harming, he died on January 23.

"Emmett's family feel strongly that had he received the support he so greatly needed his tragic death could have been prevented" - Chris Callender

"His mother and the family remain devastated that repeated calls for help simply fell on deaf ears.

"Emmett’s family feel strongly that had he received the support he so greatly needed his tragic death could have been prevented, and are relieved that the inquest has supported their concerns.

"Throughout the five day inquest the coroner heard evidence of a general, and yet very basic system failure to ensure adequate care for Emmett resulting from a lack of staff expertise, supervision, team communication, record keeping and case review.

"The consequences of such failings have been quite devastating, and the family are now calling on Kent and Medway NHS and Social Care Partnership Trust to ensure that immediate measures are put in place to prevent future tragedies, and that any such measures are communicated to the public to provide reassurances to those who rely on the service for their own wellbeing, and the wellbeing of their loved ones.”

A spokesperson from KMPT said: "We were truly saddened by the tragedy of Mr Gillah’s death and offer our sincerest and deepest condolences to all those who loved him.

"We have fully accepted all recommendations made by Her Majesty’s Coroner and are ensuring that changes made, are properly embedded in our services."

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