A 17-YEAR-OLD boy took his own life by standing in front of a train in Bath, an inquest ruled.
Coroner Dr Peter Harrowing said his conclusion was that Joao Marcelo Mulaba, who was known as Marcelo, deliberately took his own life and ruled it as suicide.
He criticised the lack of communication from Wiltshire and Bath Child and Adolescent Mental Health Services (CAMHS)and partner agencies and their speed in making improvements after a serious case review, whose conclusions have not yet been implemented.
Marcelo, was studying music at the Bath Studio School but living with a foster family in West Lavington, near Devizes, when on October 2, 2017, he entered the railway track in Bath at Sydney Gardens just before 4pm and stood in the track.
Two off-duty police officers, Andrew Abbott and Emma Kirby, saw him standing still moments before he was struck in the chest by a train leaving Bath Spa station at 35mph. Mr Abbott called 999 as did the train driver. Marcelo was still alive when paramedics arrived. He died in Southmead Hospital two days later from traumatic brain injuries.
Born in Kenya, Marcelo came via Angola to Bath to live with his mother and step-father. He moved to West Lavington in May 2017 to live with his foster mother Eleanor Preston-Gill and her family after he had left home following a dispute with his mother.
He had had a history of mental health problems since 2013 when he was first referred to CAMHS in Bath. They discharged him in April 2017.
In the summer he was seen by GP Dr Kostelnik who prescribed anti-depressants to combat depression, voices and feelings of anxiety. Mrs Preston-Gill arranged for him to have counselling.
Dr Harrowing heard that initially the medication worked but later his mental health deteriorated.
Days before the suicide attempt, the GP tried to get the Wiltshire and Bath CAMHS involved but despite repeated attempts both they and social services failed to respond.
After the hearing Mrs Preston-Gill said she was not happy with the way CAMHS had failed to tell her about Marcelo’s health problems and their lack of support for the family and Marcelo in 2017.
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