Nineteen-year-old Parys died from a drug overdose in the Wolsey Hotel on August 13, 2019, after being discharged by NHS mental health services after a long battle with mental illness. His inquest heard that despite having a history of substance abuse, Parys was able to access addictive stimulants such as Diazepam by separately visiting an NHS psychiatrist, private psychiatrist, GP surgeries and A&E. In a statement read on the first day of his inquest, his mother Alison Lapper said ‘huge changes’ were needed to stop a similar tragedy happening again. “I feel Parys was let down badly by social services and at the very least huge changes need to be made to stop this happening to somebody else’s child,” said Alison, who posed nude for a sculpture while pregnant with Parys, that was displayed in Trafalgar Square in 2005. “I cannot tell you the heartbreak I feel. Parys was loved so very much by so many people and will be greatly missed.” Born in 2000, Parys featured on the BBC series Child of Our Time, which followed millennium babies from their birth through to adulthood. The inquest heard Parys was bullied as a child and began taking drugs at the age of 13. In her statement, Alison said previous traumas began to take their toll from his mid-teens and he became withdrawn, anxious, stopped washing and stayed in bed all day. He began smoking cannabis and drinking heavily to ‘make himself feel better’, she said, to the point he stopped going to school and socialising. At 17, Parys was diagnosed with a number of psychological conditions including ADHD, PTSD, social phobia and anxiety and, in a letter to social services, his GP warned failure to intervene could prove ‘fatal’. He was referred to children’s support services, relied on his mum to shop, clean and cook for him and used drugs and alcohol ‘to the extreme’. “He was depressed, anxious and struggling,” said Alison. In 2018, Parys was given a room at Sanctuary Supported Living in Lancing and fell under the care of a new NHS mental health team – a situation described as ‘less than ideal’ for someone with social phobia by his new clinical psychiatrist Dr Arun Ravivarman. In November that year, Parys was prescribed medication to treat his ADHD, to be collected in person every week. Parys attended one meeting with a man named Terry who he introduced as ‘his uncle’. According to Alison, Terry had been allowing Parys to stay in his Brighton home ‘in return for sexual favours and drugs’. On one occasion Terry was allowed to collect Parys’ prescription for him. Over the following months Parys did not engage with his NHS psychologist, the inquest heard, but secretly began seeing a private psychiatrist in London, Dr Richard Duffett. Dr Duffett prescribed Parys Diazepam – an anti-anxiety medication that Dr Ravivarman had refused to prescribe due to its ‘high risk of abuse’ – as well as further medication for his ADHD. There was no central database to flag Parys was on multiple prescriptions. Parys took all 14 Diazepam tablets prescribed to him in one go, the inquest heard, and used the rest of his medication ‘to excess’, mixing it with substances including ketamine and heavy duty painkiller tramadol. Parys began to deteriorate physically, losing weight and failing to take care of himself, but Dr Ravivarman said there was no indication of a deterioration in his mental health. In July, 2019, he was discharged from the NHS mental health service for ‘failing to engage’ and encouraged to seek support for his substance abuse. During this time Parys had been accessing prescriptions from a third source – his GP in New Pond Row Surgery, Lancing – who in July stopped prescribing his medication as they felt he was abusing it. On July 24, Parys registered with a new GP, Selden Medical Centre in Worthing and was prescribed more medication as his medical records took time to be transferred over. He contacted Selden Medical Centre several times thereafter, until August 8, claiming to have lost his medication or asking for more due to a change in symptoms. Medical records showed his weight fell at one point to 53kg – up to 17kg less than his ‘natural’ weight. On August 13, Parys was found dead in the Wolsey Hotel in Brighton Road, Worthing. West Sussex Senior Coroner, Penelope Schofield, ruled he died of respiratory depression and a mixture of opiates and prescription medicine. In her statement, Alison remembered her late son. “Parys was my miracle millennium baby,” she said. “He was like a whirlwind, never sat still, never stopped talking, had such an inquisitive imagination. The biggest blue eyes that would melt the heart of everyone he met. He was funny, sensitive and very loving. “I will never forget the day that police knocked at my door to tell me that my beautiful, funny and sensitive boy, that I loved, had been found dead and alone and had been there possibly for a couple of days.” The inquest continues.