A mum who lost her son to suicide is calling for England-style inquests to be introduced to help prevent other families going through what she suffered.
Forfar mother Catherine Matheson accused NHS Tayside of failures over her schizophrenic son’s care, including not recognising that his attempts to swallow glass and cutlery were suicide bids.
She urged MSPs to push for reform because the system as it stands means too often families do not get answers and lessons are not learned.
Mrs Matheson found her 35-year-old son David Gordon hanging in his loft in 2012.
She told a Holyrood committee: “Nothing I do or say will bring my son back, or my daughter’s brother, or my grandson’s dad.
“But the fact is if we can get a system that has a process that properly investigates these things that have gone wrong, that is the only way we can improve that system.”
She added: “I don’t want anyone else to go through what we have gone through.”
Ms Matheson said hearings into suicides are not automatic and relatives have to endure lengthy waits while the procurator fiscal decides whether to hold a Fatal Accident Inquiry into the death.
She wants a similar system to the one in England, where inquests are held into unnatural deaths, including suicide.
In her son’s case, she said NHS Tayside had not carried out a “full and accurate report, as they promised, on their final episode of care for my son”, which left her bereft of answers and deprived the system of improving care in future cases.
Mr Gordon under a compulsory treatment order after his release from hospital in April 2012 and was being treated by the community mental health team. But staff had not been following up appointments he had cancelled, Mrs Matheson said.
His sister Kate said the health board did not recognise he was trying to kill himself.
“They denied (that) continuously throughout his care even though he had been swallowing objects, he’d been swallowing glass, cutlery – anything he could get his hands on in his hospital,” she said.
Johann Lamont MSP, convener of the public petitions committee, said they were “deeply moved” by Catherine Matheson’s evidence, who she said had “presented challenging issues with immense bravery and clarity”.
“The committee now wants to investigate ways to help ensure Catherine’s experience is not repeated for other families in Scotland,” she added.
An NHS Tayside spokeswoman said: “As this is a legal matter, we are unable to comment.”