To Whom It May Concern,

I am writing this in the hope of helping me understand why I lost my son James at just 29 years old. To others, he is just a statistic - another drug's death. But he was my beautiful boy. I am sure the current police investigation will conclude he was an adult who made a choice that resulted tragically in an accidental overdose.

I strongly feel that there were so many missed opportunities that may have changed the course of events and I hope that services will take the time to reflect and learn. And of possible policies or practices to change to reduce the risk of another mother going through this unbearable torture, a mother's worst nightmare, and hopefully, even save just one young life from ending before it should.

James was born on the 21st of July 1993. James with his blonde hair and beautiful blue eyes as a young child was full of life, rarely slept, and was always looking for challenges. He struggled in school, being diagnosed with dyslexia with little support in those days. High school was difficult for him. He coped with struggling to concentrate by obsessively fishing, skateboarding, and trail biking. Even at this point, I was very worried about his behaviour and mental health. At 15 years old he was assessed by a child psychologist. His reading and spelling have not improved since his primary assessment. He was continuously excluded and asked to leave school. James was at this stage using cannabis as a coping mechanism. Early intervention and mental health support at this stage may have been beneficial - but this proved impossible to access.

James then went to college and with support was top in his Introduction to Construction Skills course. He then gained a bricklayer apprenticeship. Unfortunately, my daughter was diagnosed with cancer at this point, and James increased his cannabis use and dabbled with other drugs, again using this as a coping mechanism he believed for his struggling mental health.

He began to get noticed by the police, fighting and being under the influence. In 2011 he was arrested and kept overnight at just 16 years old. He was assessed by a doctor who stated he could not make a connection with James and was concerned about his behaviour.

Three years into James's apprenticeship, James lost his job due to his attendance and concentration. James moved to England with his girlfriend. I am unaware of the events that followed in England, but he was hit by a car while on his bike and returned a very different young man. His relationship broke down, and he phoned me, suicidal, believing he was being set up for murder with bodies under his floor, wishing to end his life by jumping off a bridge. He was again arrested and returned home.

James was provided supported accommodation by Blue Triangle and Carr Gomm, and I pushed for a mental health assessment. He was diagnosed with ADHD, Bipolar and drug-induced psychosis. Unfortunately, mental health support was months apart and around 3 appointments with no CPN input.

 In 2016 James was taken by ambulance, unconscious, with his first heroin overdose. I knew he needed Naloxone but was questioned as I begged the nursing staff to administer this. James was no longer receiving mental health support. His life spiralled out of control, being advised not to work due to his mental health, and as this would affect his benefits and his housing, increased benefits enabled daily use of any available substance. James was on and off methadone, had sporadic engagement with addiction services, had mental health medication not available due to his substance use, was seen as extremely high risk but had no psychosocial interventions, and his mental health rapidly further declining.

In 2018 James was offered a tenancy. Carr Gomm called a meeting with housing, Blue Triangle, WHHA and me stating that James was not ready for a tenancy due to his poor mental health and his inability to perform daily tasks. He had a different sense of reality from others due to further drug-induced psychosis. He had no mental health support and limited addiction support, yet housing stated, "There is no such thing as not ready". He had no option but to take the tenancy or be roofless.

James's life quickly spiralled further, with the only professional support from housing services Carr Gomm. Mental health medication had not been reviewed, with no provision made for daily supervision, with James unable to gate-keep, maintain his flat in a livable condition or even manage his own basic needs such as hygiene or food. James had an altered sense of reality and fell deeper into the addiction spiral. At this point, James was a danger to himself, and a danger to others as well as a danger from others. James was stabbed in his own home, his door smashed in, and he lived in continuous fear of his life. I received daily phone calls from the police asking if I was able to check if he was alive, or if they would.

In June 2019 James was moved back to supported accommodation for his safety but again no mental health input. James was again arrested, within one day, and forced to return to his accommodation. I supported James in attending the addiction clinic in May 2019, where James asked for an inpatient detox and a mental health assessment. We were told this was not available. He was offered no medication as seen as too high risk of overdose. Again, he was offered no mental health treatment.

At this point I emailed my local counsellor asking why this was not available, and crying out for help for my son and the effect it was having on my family, begging for help to keep James alive! Unfortunately, James was arrested in June 2019 before any support was given. In prison James was kept safe, but again no mental health support.

James was released on 6th September 2020. He wished to stay in Glasgow as he believed support may be more available or return to Oban to be close to family and friends. James was offered homeless accommodation in Dunoon with minimum support in place. Within a month James was again arrested, taken to court in Glasgow, and released the following day with nothing - no accommodation, no money, not even a jacket.

James managed to find his way back to Oban. He was frustrated, angry, and in emotional turmoil. He was refused any accommodation and returned to Glasgow, where the street team found him roofless and offered him temporary homeless accommodation. Again, James was arrested in December 2020 and spent a short time on remand. Again, he was released with nothing. Every time he lost his accommodation and his benefits. Once again, the homeless team assisted, and he was supported by the addiction team who prescribed him Espranor. For a period, the chaos was less.

Unfortunately, James had to return to Argyll and Bute as they had the duty of care being his local authority, with no local connection in Glasgow. James was then provided homeless accommodation in Helensburgh. Unfortunately, Argyll and Bute did not prescribe Espranor at that point, and his medication was abruptly stopped. James was isolated, his life in chaos with little support, and no mental health input, and was suicidal due to threats on his life in Helensburgh where he was seriously physically assaulted and fled to Glasgow.

Again, he spent some time being homeless until the street team found him accommodation. Both his physical and mental health further declined, being moved on from various homeless accommodations.

On James's birthday, 20th July 2021, I received a call from the police as James had been registered as a missing person from the homeless team. There were concerns for his welfare. He had overdosed but was found. In October 2021 James returned to Oban.

James had no GP, no mental health support, and no benefits and was refused accommodation in Argyll and Bute. Even though Glasgow stated they could not provide accommodation, he was to be accommodated within his local authority of Argyll and Bute. His physical and mental health had further declined. I supported James in registering with the local GP, applying for benefits, and gaining accommodation within a private bedsit.

Again, there was no mental health support. James was again arrested, with a DTTO assessment requested by his lawyer, who was concerned about James' welfare. Unfortunately, due to James's mental health, he was assessed as not suitable for the DTTO - and still, no mental health support was provided! Why not?!

James became further and further detached from reality. In April 2022, James was arrested for ‘bank robbery’. He believed the bank was withholding his benefits, part of the conspiracy to control his life, and wanting him dead. James was in the police cells in Oban, naked, screaming, and in total mental turmoil. He was assessed on this day by at least one GP, not a mental health specialist, and deemed fit to be detained, but unfit to stand in court. He was then forcefully taken into police transport, taken around 100 miles away to the prison, and put on suicide watch. One small room, with no company. How can this be? Why was there no follow-up mental health assessment?!

James was taken to Barlinnie prison in April. His lawyer knew him well, stating she was particularly concerned about James when he was taken into custody about these offences. She requested an independent psychiatric assessment, to assess if James was fully fit to participate in the criminal proceedings and the state of his mental health at the time of the offence. This was agreed upon by the court. Although James was detained in April, on 26th September, 5 months later, James had still not been assessed. His lawyer informed me James was due to attend Dumbarton court the following day, and the mental health assessment was scheduled for that day – the 26th of September. In my opinion, five months were wasted for James, sitting in a cell with his mental health further declining.

James told the psychiatrist to fuck off. He trusted no one at this point. Surely even that would even be cause for concern. There was no further follow-up. James had been the least under the influence in a very long time at that point with the psychiatrist within a safe and secure environment. I feel this was a missed opportunity to see James's state of mind that the police and the lawyer had seen.

On 28th September 2022, I received an email from James's lawyer, stating James had been sentenced to 8 months imprisonment, backdated to 6th April. She believed this would not affect his liberation date of 10th October. As James had no accommodation, no bank account, no benefits, and no ID, he would need an appointment with social workers before his release to assist him.

I encouraged him to make this appointment although he was too afraid and paranoid to do so. Unfortunately, he was released unexpectedly the next day, with no opportunity to ask for assistance. James had absolutely nothing, and no one was aware! I heard nothing from James for a few days, which was very unlike him - no one did. I then reported him as a missing person as he was extremely vulnerable, with absolutely nothing, unprepared practically, physically, or emotionally for his release. With the help of social media, I found he had overdosed and was in the hospital for 2 days with no ID. Before I physically got there or even spoke to him James had self-discharged to the streets of Glasgow once again.

Once again with the assistance of social media, friends of James and the police, we found James. How can a vulnerable person, clearly with mental health and addiction issues, be released from prison time and time again with nothing but the clothes he was wearing? No accommodation, no change of clothes, no benefits in place, no bank account, no ID, no phone, and with no support agencies or family aware, into a city almost 100 miles from home?!

Figures clearly show the increased risk of drug death and suicide when released from prison. Surely there should be better support in place to reduce these risks. I contacted our local authority, Argyll and Bute council, and homeless accommodation, to be advised the only available property was in Helensburgh, the exact block of flats that James had fled from! James was exhausted and agreed to this. I maintained communication with the local homeless officer, who advised it would be easier if we presented before 5pm, especially as it was a Friday. I explained that I was traveling from Oban liaising with James and his friends assisting him and hoped to be in Helensburgh by 2pm. We all arrived together just after 1pm. I then phoned the homeless officer who advised we contact the Helensburgh office, who was aware. Unfortunately, the Helensburgh officer stated James had been informed to present by 12pm, therefore he was now too late. I am sure you can understand our frustration! At no point had anyone from the housing department spoken to James - we were trying to find James on the streets in Glasgow! Where was the empathy and compassion considering their position?

After discussion, it was agreed I collect the keys for the accommodation from the housing officer. I was handed the keys while James remained in the van with his friends. I was given one set and informed there was no time to sign for the property today.

I had previously been in contact with Carr Gomm housing support, and contacted them again, with a referral and consent form for James to ensure he had housing support. I then contacted We Are with You while James was with me. With consent given, a referral was made, and a worker came to assist James and me. We then met with the housing officer at the property. I felt anxious re-entering the same address where I had seen the extent of the injuries to James while living there previously. James stated he did not like being there, but it was a start. On entering the accommodation, the officer addressed me, all communication through me, not acknowledging James at any point, who was in the same room! Surely, as a paid, qualified housing officer, with a duty of care, this cannot, and should not be how individuals are treated!

The flat had the basics - bed, couch, white goods, but unfortunately no duvet, no sheets, no towel, no cutlery, no kettle, the essentials provided to all entering homeless accommodation. I politely challenged this, being informed it may be Monday before this starter pack would be available. I again challenged this, with thankfully a pack being provided that day. Unfortunately, the next challenge was there no electricity. The housing officer stated he was working on this and would keep us updated, as well as provide a new key for the meter. The We are With You worker noted that the meter was in debt, and enquired if this would be cleared or covered, and electricity provided, to which the housing officer agreed.

We were made aware there was no food parcel available, and the food bank was closed until Tuesday. We were advised to assist James in applying for a crisis grant, being informed ID and an up-to-date bank statement would be required. It had been explained on more than one occasion that James did not have any of these to meet the requirements.

James was exhausted, cold, and hungry. Unfortunately, with no electricity, we could not put on the heating or cook, not even a hot drink. I assisted James in getting as comfortable as possible and then left to purchase some food for the next few days until Carr Gomm was able to support James with his benefits.

The housing officer did not call back with an electricity key, and he did not answer the phone when I phoned several times. I was aware the office would be closing soon for the weekend. Before 5pm the We Are With You worker and I attended the social work office to find a locked door. After a further call and a short wait, we were able to see the housing officer again. He stated he had been unable to rectify the electricity situation but had secured accommodation for James in a hotel on the outskirts of town. He then stated I had to "assure him James would be on his best behaviour - or he would be put out"! I could not do this! The We Are With You Worker then asked if meals would be supplied as James had no way of cooking the food we had purchased for him. This food was no longer of any benefit to James. After some discussion, we were assured an evening meal would be provided while there was no electricity in the flat. The We Are With You worker, and I returned to explain this to James. With James exhausted from sleeping rough and overdosing, with wet sore feet, hungry and cold, we supported him with some difficulty to the hotel.

Without the support of the We Are With You and I there was no way James would have been physically or mentally capable of securing his basic needs that day. James was grateful to be warm, have a bed and have the chance to wash. Unfortunately, the hotel did not provide evening meals. The housing officer did not check this. They provided breakfast only, at an agreed time, with the menu to be chosen the night before. Surely the homeless team should have been aware of this. I then purchased snack foods for James, so he had something.

With James as settled as possible, and referrals to We Are With You and Carr Gomm I had hope that life may improve. My daughter drove the 160-mile round trip the following day to ensure James had food and more clothes as well as family support over the weekend, with his Carr Gomm appointment for Monday in place.

At this point, James had no GP, no opioid replacement, and no mental health medication. He had no bank account, and opening one without ID would prove challenging, with no benefits in place, and therefore no housing benefit again with ID being an issue. The agencies were supporting this as James was not mentally or physically able to do this without support.

On Monday 10th October James attended Carr Gomm. The walk from the hotel to Carr Gomm was difficult for James. He was confused, angry and upset, with little achieved that day to improve his situation. He was also due to appear in Oban court on Monday 17th October. This would not be physically or financially possible. I spoke to James on the phone that same day. Again, he was confused and angry. He had not yet seen a doctor.

Around the 13th of October, Carr Gomm raised an adult protection investigation as they were concerned for his mental health and believed he was a risk to himself and others. They were struggling to support him due to his mental health. Due to his state of mind, I also requested an adult protection investigation as I was extremely worried about James.

James had a criminal justice social worker, with James to attend appointments voluntarily. I also raised my concerns to his worker. James' behaviour was erratic, and his life was still very much in chaos.

Carr Gomm and I hoped that an adult protection investigation would assist James, with a mental health assessment and addiction input to be part of a harm reduction plan with all agencies involved working together. In the opinion of many James had limited capacity, an altered sense of reality, very likely psychotic, and a risk to himself and others.

On 18th October I received an email from Helensburgh housing department stating James was refusing to vacate the hotel. The electricity was now working so he must return to his flat. If he did not leave within 2 hours, they would phone the police. How was this supportive? On 11th November I received a phone call from Govan police station stating James was again in custody and would be appearing in court the following day.

By 14th November absolutely no one had seen or heard from James. Yet again he was invisible, still with no ID, no benefits, and no medication again having been released onto the streets in Glasgow, with no way of returning to his accommodation in Helensburgh. As far as I am aware the adult protection investigation had been completed. Agencies had been spoken to. Had they spoken to or seen James? Was there a plan in place? Why had nothing changed? Why was no one even aware of what James was arrested for and no one knew where he was despite his state of mind?

James was alone again in Glasgow with nothing and no one. James phoned me later the 14th, stating he had been arrested from his flat, unaware of what his charges were. He stated the street team had a bed for him that night, but he had no way of returning to Helensburgh. I advised I would speak with his social worker to see if they could help, and if not, I would drive to Glasgow the following day. I did phone social work, requesting they support him to return. They stated this was not possible, and they could only support James when he returned to Argyll and Bute! They suggested I buy him a bus or train ticket.

With James having no ID or bank account, as well as no phone of his own, he would not have been able to access any ticket I would have purchased for him. James was not in a fit mental state to engage with support in Glasgow, or indeed find the correct support. I had been informed, while James was in Helensburgh, that I was to choose if I supported James, or the agencies did! This goes against MAT standards where family and community are a large part of recovery, as well as being against a mother's instinct, fighting hard to try and help her son recover from addiction, associated severe mental illness, life in chaos and total torment. The family impact was also huge.

Unfortunately, James was again arrested that night. I received yet another heartbreaking call from James. I was out at the time, and his voicemail stated he was in Barlinnie. He asked me to find out what his charges were and if I could please visit him and bring some clothes.

The prison visit rules had now changed. Unfortunately, now it was the responsibility of the prisoner to book a visit. James was not mentally fit to do this. I phoned the prison with my concerns for James' mental health and requested assistance in making my appointment to see James. I never got to see my son for one last time.

James's local lawyer asked the crown for the details of the Glasgow lawyer representing James on this occasion and requested what his current charges were. We are to this date still unaware.

I emailed James on many occasions. On 18th November James sent me his last ever email. In it, he asked if I could come and see him one last time. He spoke of demons, skulls and bones, rooks and wanting to end his life - to go to Valhalla - stating he felt like he should be in a mental hospital and that someone was trying to kill him. This was heartbreaking to read. I also received a message from a recently released prisoner who was concerned for the mental health of James.

I again phoned the prison with my concerns. Why was this email allowed to be passed? Why was the prison not concerned with the content of the email? Why would the prison not assist James in arranging a visit for me?

I was told, "It's like you have a bad night and write it on Facebook. He is safe and well". I was not convinced and continued to email James, but sadly with no reply ever. On Tuesday 13th December James phoned me stating I no longer needed to visit as he was sure he would be getting released at some point before Christmas. We agreed I would pick him up when he was aware of his release date. This was to be my very last conversation with my son.

On 16th December 2022, at 4.50 am my doorbell woke me. I opened my eyes and immediately thought - James - police. I walked down my stairs with fear and dread - and through the glass saw two policemen. I opened the door and asked, "Is it James?" The day I had feared and dreaded, had nightmares about, was today. Every mother's worst nightmare.

My son was dead.

I watched the snow fall behind the Christmas tree and hoped I would wake from this nightmare. James had been released on 14th December straight from court. Again no one was made aware.

James would have been cuffed in the prison van, cuffed in the court, and then released just in his prison clothes yet again.

James did not have a jacket in sub-zero conditions. James had no means of contacting anyone, no way of returning to his accommodation and no support.

My son, James, 29 years of age was dead within 36 hours of being released from prison.

Why? Why? WHY??

Would early interventions have changed anything? Would the initial request for an inpatient detox and mental health assessment make the difference? Why was James not suitable for a DTTO? Why was a mental health assessment not carried out at that point? Why did the mental health assessment ruled by the court be nothing but a tick-box exercise?

Why was there no adult protection meeting?

Why was I told to choose who supported my son?

Why was James continuously arrested and then released from jail miles from home with absolutely nothing - with no one aware?

Why did the prison not take my two phone calls with concerns seriously?

Why, when the risk of overdose and suicide is so high from release from prison, did James have nothing in place each time?

What went wrong?

Why is my boy dead - MY BOY?

I don't know the answers to any of these questions, and possibly never will. Could the prison have done more? Could the mental health team have done more? Could the addiction services have done more? Could social services have done more? Could housing have done more? Could the court have done more? Could the GP have done more?

The following month I received a phone call from my friend. Her son is dead. He had been released from prison 3 days ago.

What is going on?

What MUST be changed?!

I now visit James in the cemetery. James was 29 years old. He lies beside his 30-year-old friend.