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00:00Today we are grateful to the coroner for hearing the evidence around the care of
00:03Duncan in the lead-up to the tragic death of our parents and although
00:07devastating we really welcome her findings today.
00:11Our best efforts as a family to get Duncan the care he needed went unheard
00:15by many of the health and social care services charged with his care.
00:20These failings, missed opportunities, system errors and lack of professionalism
00:25contributed to tragic circumstances we walked into on the morning of Sunday the
00:3027th of November 2022. Almost two years on and it has been a long frustrating
00:37and mentally draining battle for us to get this heard. It has not been helped by the
00:42lack of communication and transparency from those organisations in which all of
00:47us place so much trust. Our parents provided a safe and loving environment
00:56for us to grow up. They were caring members of the community, close family, friends and
01:01neighbours who loved them and their loss is an enormous hole in our lives and
01:06everyone else's. We want to continue to work towards creating a better future
01:10for the users accessing services that failed our family in order that no other family
01:15feels the same tragic loss in their lives that we have to live with every day.
01:20In particular we are passionate about ensuring that national care pathway is
01:25implemented for people like our brother who had a complex set of circumstances
01:29which needed urgent assessment and treatment. As a family we will still
01:34stand by the statement that our parents sacrificed their lives so Duncan could get a diagnosis of a serious mental illness
01:41and it should never have been this way.
01:44We have all paid a price in this tragedy and those of us that remain will continue to battle with its aftermath.