Sadly, it is my resolute opinion that this GP was largely responsible for our son's death, due to her failure to act, inform, and co-operate with either us—his parents and his only support—or the Mental Health Trust, which was itself disorganised and misaligned with recommended practices. As a result of damaging experience before our sons death—which I believe was entirely avoidable—I would not be able to recommend this GP for involvement with mental health problems in young persons; nor for her knowledge of local or national mental health procedures, including the Mental Capacity Act (MCA) for duties of care, and NICE guidelines for dealing with mental illness. I would also not feel able to recommend this GP to carry out comprehensive and forthright investigation complying with the NHS Complaints process, despite the acute nature of such complaint as received and processed by the Trust as a Serious Untoward Incident. Consequently, the Health Services Ombudsman was unable to understand and resolve the issues at stake –but this in itself is quite common. Following my son’s Inquest—from which the GP was ‘excused’—and a legal Claim on the NHS Trust, responses by the Coroner and Trust confirmed my opinions with regard to lack of collaboration and support, and that the Practice failed to follow MCA procedures or act in my son’s best interests therefore denying him options for treatment. I am now aware that Birmingham and Solihull Mental Health Trust did have procedures for better patient, carer and GP engagement. It is now trying to improve mental health knowledge, by offering training for GPs regarding their responsibilities to patients and their carers; and of the importance of good communications and record keeping in this area of illness. I would urge that this GP Practice improves its handling of mental illness through an all-inclusive approach with Carers and NHS Trust services, via up-to-date training, and maintaining the vital communications as directed Nationally. I have yet to hear that GPs have committed to change their approach at this Practice, however. My experience relates to events from June 2003 up to mid 2009, when I chose to leave this Practice. Lessons from my son’s death are still not fully resolved despite positive changes within the Trust. The new CCG, NHS England and GMC have been advised and are aware of failings. An investigation is still needed.