A young father who became frustrated with the length of time it took him to receive support for his ADHD and autism took his own life, a court has heard.
Aaron Gordon was found face down in water off Marston Lane at Marston Marshes nature reserve, on the outskirts of Norwich.
Despite the efforts of members of the public and paramedics, the 22-year-old, who had worked as a removals man, died there from drowning.
An inquest into his death, held this week at Norfolk Coroner’s Court, harrowing details emerged of the long and tortuous waits that Mr Gordon had faced to receive support for his mental ill health.
He died less than a fortnight before he was due to attend a key appointment.
A TRAGIC DISCOVERY
Shortly before 7am on March 4 this year, a member of the public came across a black coat with a bank card inside a pocket along a footpath off Abinger Way, Eaton, that leads to Marston Marshes.
Moments later, he saw the body of Mr Gordon in the river. He pulled the young man out and attempted to give CPR.
As this was unfolding, another man, a runner who had found more items of clothing strewn across the path, also got involved to help.
Along with more passersby, they offered support and called 999. However, emergency services workers pronounced Mr Gordon dead at the scene.
An investigation began and the marshes were cordoned off. In the area, police found clothes, a mobile phone and a framed photograph, all of which led them to quickly identify Mr Gordon.
FAMILY’S HEARTBREAK
His mother, Wendy Goodall, told officers he had left a bag of clothes on her doorstep the previous night, which she had only discovered that morning.
She also said her son had shared a Facebook story that said: “It’s too late now, goodbye.”
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His girlfriend, Maudie, revealed that the night before he was found, the couple had argued and he had left their home. They had continued to message each other during the night.
His mother and siblings attended the inquest, affectionately describing him as having a “stubborn” personality.
A LONG HISTORY
The court, based at County Hall in Norwich, heard that Mr Gordon, of Horning Close, Earlham, had a long history of mental ill health.
Evidence from his GP, at Wensum Valley Medical Practice, heard he was first referred to the Child and Adolescent Mental Health Services (CAMHS) in April 2015, aged 14.
Six months on, his mood had improved and he became involved with the young person’s charity MAP.
But by November 2015, his struggles had flared up again. This time, his GP referred him to the community paediatricians believing he may have ASD and ADHD.
However, it would take three years for Mr Gordon to be diagnosed.
During this wait, in 2017 he was referred to CAMHS. That same year he was admitted to mental specialist services at Rochford Community Hospital in Essex. Here an urgent referral was made for the assessment.
By the age of 20, he reported struggling with anxiety and ADHD and was regularly using cannabis.
He was seen by the Wellbeing Service in November 2021, before a suicide attempt which he told people he had made because of “his frustration over taking so long to get support”.
By 2022, and now grieving the loss of his father, he was experiencing further anxiety, anger issues, cannabis misuse and nightmares.
The GP’s evidence described how “he felt okay for some time and then something else comes along and drags him down again”.
By October, he was given medication to help with his mental ill health. This was then increased following his grandmother’s death in March 2023.
In April 2023, he took an overdose before highlighting to medical professionals that he was still on the waiting list for focused interventions.
Two months later he had become emotional, tearful, anxious, restless and depressed. He was also struggling to stay in employment.
He was given ADHD medication but just four months later he faced further stress when he was told there were availability issues with the drug.
Following his death, Waveney Valley Medical Practice held a 'significant event audit'.
This highlighted that lessons had been learnt, including “possibly delayed diagnosis of neurodevelopmental issues and frustrations with him about the time it took to get help”.
A WAITING GAME
In a report to the inquest, Nicola Rice, an interim lead nurse of the Norfolk and Suffolk Foundation Trust, which runs mental health services, explained that Mr Gordon’s ASD and ADHD assessment had been carried out urgently in 2017 after he was sectioned under Section 3 of the Mental Health Act. He received the diagnosis in 2018.
Following this, he continued to be seen for further investigations in regard to ADHD and autism, and for behaviours and emotional regulation strategies.
He was signposted to the autism pathway under the Norfolk Community health and care trust for support after that.
He had expected to be signposted to Think CBT in 2023, for cognitive behavioural therapy, but was told he did not meet the criteria due to his cannabis use and recent overdose.
By September 2023, he was on the waiting list for an intervention for low mood and was told he would receive a medication review appointment in 12 months' time.
Unable to wait a year, he called the youth team in February 2024 requesting a medication and ADHD review as he was worried about his symptoms.
An appointment was made for March 13, but he died before he was able to attend.
Speaking to the court, Mr Gordon’s mother, a former worker at Hellesdon Hospital, said she had seen him the day before his death.
She said: “Aaron had his mood swings from an early age really. I tried to get him the help when he got let out of Rochford.
“I tried to tell them that he wasn’t well enough to come home.
“I told them straight he wasn’t well enough.
“We all tried to help him, all of us. He was a stubborn one.”
CORONER'S CONCLUSION
Summing up the evidence, Jacqueline Lake, senior coroner for Norfolk, said: “Aaron had a long mental health history and had been under the mental health team for many years dating back to 2015.
“He did have a diagnosis of ADHD, and he was due to have an appointment with the team but that was shortly after his death.
“I am satisfied from the evidence that Aaron took action, and he intended from that action to end his life, so my conclusion is suicide.”
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