A former teacher who went missing in Thurston last November was “crying out for help”, a court heard.
On Tuesday, the inquest of Martin Canter was heard before Suffolk Coroners’ Court in Ipswich.
Dr Canter, 62, died in the early hours of November 10 last year after being reported missing by family two days earlier.
The court heard that Dr Canter was an educational development specialist and adviser, and had worked abroad including in Sierra Leone, Indonesia and Timor-Leste.
Before that, he worked as an English teacher at comprehensive schools in the UK, where he had become head of department.
Dr Canter’s mother and two sisters were present in court and described him as a very gifted man, who they said was “thoughtful”, “inspirational and “eclectic but always curious”.
They reported Dr Canter missing on November 8, after realising at around 8.30am that he had left the family home.
A search was commenced by Suffolk Police and Suffolk Lowland Search and Rescue (SULSAR), with a helicopter being used in the hunt to locate him.
Dr Canter was found in woodland area in Thurston late on November 9, unconscious.
The inquest heard that he was later found to have alcohol in his system, and had taken a large quantity of medication, which was found beside him.
Dr Canter was taken by ambulance to the West Suffolk Hospital. However, attempts to resuscitate him were unsuccessful, and he died in the early hours of the following morning.
The court heard that Dr Canter struggled with his mental health for many years, dating back to his time in Timor-Leste, when he was prescribed antidepressants.
He also struggled during the Covid lockdowns of 2020, having returned to the UK in 2017 and taken up a job in London.
Things worsened in 2023, by which time Dr Canter was living with his family in Thurston. Dr Canter told his family that he was having thoughts of suicide.
In October, he confessed to having walked to nearby woodland with plans to end his life, but had changed his mind and come home.
Dr Canter called 111 on October 15 to speak about his suicidal ideation. He also expressed fears that he was suffering from dementia from previous alcohol use.
The call handler advised Dr Canter to engage with his GP, which he did. He attended an appointment the next day, where it was agreed that a referral with mental health services would be made.
It took until October 23 for this referral to arrive with the Norfolk and Suffolk NHS Foundation Trust (NSFT).
That referral had to be resubmitted again on October 31, due to having inadequate information.
Presiding Coroner Darren Stewart OBE said he would be asking the GP surgery, Victoria Surgery in Bury St Edmunds, for an explanation as to the delay.
By this time, Dr Canter had made contact with mental services himself.
At the time of his death, there were two appointments scheduled with wellbeing and mental health services, one on November 13 and another on November 23.
Dr Canter was also seen by a psychiatric nurse at Victoria Surgery on November 2.
Dr Canter told the nurse that, while he was experiencing suicidal ideation, he had the support of his family did not intend to carry out these thoughts.
The nurse was satisfied that, should Dr Canter would be able to wait for his appointment on November 13, and that if he experienced another acute episode, he would be able to access support.
“Very sadly, that is not what transpired,” said the coroner.
Dr Canter’s family felt that the complicated process of asking for help may have frustrated him.
“He was crying out for help,” said his sister, Christina Canter.
She said that Dr Canter had contacted every organisation suggested to him, such as Turning Point and the Steam House Café in Bury St Edmunds.
Mr Stewart said that he did not believe mental health clinicians could have anticipated Dr Canter’s death.
On November 2, he presented as someone who was engaging with mental health services and had the capacity to keep himself safe, and he said the nurse had no reason to suspect he would not be able to make the appointment scheduled 12 days later.
The coroner recorded that Dr Canter took his own life. He ended proceedings by offering his own condolences to Dr Canter’s family.
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