THE LAST time Adam Stanmore was seen alive, he was in the ‘most vulnerable place in his life’ and desperately needed help.

But his mother, in a statement read to jurors at Oxford Coroners’ Court yesterday, said that ‘all the opportunities’ were ‘missed’ by police, paramedics, doctors and mental health services.

Mr Stanmore was found dead in an Oxford woodland on June 13, 2019 – weeks after he went missing.

In a summary of the events leading up to his death, the court heard how on April 23, 2019, he had phoned the GP asking for an emergency appointment after hearing voices saying that his mum and brother would be killed if he did not kill himself.

The doctor said he was having a drug-induced psychotic episode and referred him to a mental health team for an appointment that day.

He went to it with his mum Sandra Harris and they gave him a ‘slip of paper’ with details to a charity and no follow-up appointments were made.

In a statement read on her behalf to the court, she said: “Adam turned to me and said ‘well that was a waste of time’.

“He wanted to get help but did not feel that this was helpful at all.”

She said he didn’t seem right in the weeks following and, on May 17, he stayed at her house.

But instead of sleeping, he paced up and down the living room, taking clocks off the wall and covering lampshades with clothes.

She described not knowing what to do, just hoping he would get some sleep.

But when she woke up she found a note from her son, who had spelt his own name wrong, saying he needed to get away and had taken insulin and some money – leaving her enough for bingo.

In the events that followed, the assistant coroner for Oxfordshire Sonia Hayes said he had banged on a neighbour’s door asking for a knife – who handed one over before calling the police.

Officers arrived and found Mr Stanmore sitting on a wall of a residential street – they then used a Taser to arrest him and drove him to the station.

But in custody, a sergeant decided that he needed to be seen at hospital.

Paramedics arrived to take him to A+E but he discharged himself from their care on May 18.

Later that day he saw police officers again – they were the last people to ever see him alive.

Mr Stanmore’s friends drove around the area in the days that followed, searching the streets to find him.

His mum waited at home in case he returned.

In an effort to help him, money was also transferred to his account so he could withdraw it.

But on June 13, the 37-year-old was found dead in woodland behind a street.

Jurors at Oxford Coroners Court must now listen to all the evidence and witnesses over the next few weeks and decide a conclusion on how he came to his death.

The coroner said their decision will be based on the answers to questions like: ‘was his medical assessment on April 23 and any follow-up adequate?’, ‘did he have the mental capacity to discharge himself on May 18?’, 'was his risk of suicide conveyed to Thames Valley Police?', 'when he didn’t arrive at hospital, was this taken seriously?'

Sharing a tribute to the dad, his mum who has just been diagnosed with a terminal illness, wrote: “He was a loveable person.

“He was loyal, he loved to play a prank. He was highly intelligent and a deep thinker. He was quick-witted. He will be very much missed.

“I feel there were so many opportunities to get the help he needed but these were all missed. Adam was in the most vulnerable place in his life and he was let down.”

The inquest continues. 

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