Suicide Awareness Month: Every Story Begins Long Before the Ending
But after years of investigating coercive control, safeguarding failures, mental health, suicide, elder financial abuse and institutional behaviour, I’ve become increasingly uncomfortable with how much of the responsibility for suicide prevention we place upon the person who is already struggling to survive.
September is Suicide Awareness Month.
So we’ll see the familiar messages.
Talk.
Reach out.
Ask for help.
Check on your friends.
All of those things matter.
But after years of investigating coercive control, safeguarding failures, mental health, suicide, elder financial abuse and institutional behaviour, I’ve become increasingly uncomfortable with how much of the responsibility for suicide prevention we place upon the person who is already struggling to survive.
Because sometimes they did reach out.
Sometimes their family reached out.
Sometimes a professional reached out for them.
Sometimes there were warning signs scattered across different organisations for months or years.
Sometimes the person didn’t even recognise what was happening to them as abuse.
And sometimes we only put the pieces together after they’re dead.
That has to change.
Suicide doesn’t have one pathway
This subject is deeply personal to me.
My late stepfather died by suicide in 1995.
There was no Facebook. No X. No viral post or algorithm.
But there was something much older.
Narrative control.
He’d made a mistake and took accountability for it. What followed was something different. One version of him began to dominate. It was repeated and reinforced until the mistake and the man became almost impossible to separate.
I’ve since come to understand just how destructive that can be.
My cousin also died by suicide. She’d been badly burned as a child and carried those scars throughout her life. Alongside the physical scars came insecurity, bullying, judgement and people who used her vulnerabilities against her.
My own path was different again.
As a teenager I experienced abuse, narrative control and bullying. I tried to take my own life more than once.
I still carry the scars.
So when I say at Bridge to Justice that we need to investigate the pathway, I’m not talking about something I’ve only read in a textbook.
I’ve seen different roads lead people towards the same darkness.
And I’ve spent years since seeing those roads in the lives of other people.
The dark cloud doesn’t always have the same beginning
Depression is real.
Mental illness is real.
Sometimes there may be biological, neurological, psychological or psychiatric factors that we don’t fully understand.
Sometimes that dark cloud appears unexpectedly. Sometimes anniversaries, grief, trauma, hormonal changes, illness or events trigger something that has been sitting quietly underneath.
Sometimes we simply don’t know why.
But we need to stop behaving as though every suicide begins with somebody’s brain being somehow inherently different or defective.
Sometimes depression is also a response to what somebody is living through.
Fear.
Abuse.
Humiliation.
Isolation.
Debt.
Pain.
Bereavement.
Bullying.
Blackmail.
Addiction.
Grooming.
Reputational destruction.
Workplace pressure.
Family breakdown.
Domestic abuse.
Financial exploitation.
Institutional retaliation.
Or years of several of those things happening together.
That doesn’t mean one event automatically ‘caused’ a suicide.
Suicide is complex and we should be extremely careful about simplistic causation.
It means we need to ask a much better question.
What was happening in this person’s life that made living become so difficult?
We tell people to reach out. What happens when they do?
That question is particularly uncomfortable on the Isle of Man this week.
Philip Ashley Cooper died by suicide in August 2025.
His mother was worried about him.
He’d previously tried to end his life.
His beloved dog had recently died.
His mental health was deteriorating.
His mother contacted the Crisis Response Team.
A mental health nurse then spoke with Philip, identified significant risks and considered his distress so severe that she believed he needed support immediately.
She referred him to the Crisis Response Team.
The referral wasn’t accepted.
Philip died the following day.
The coroner has been very careful, as we must be. He said he couldn’t conclude that Philip would not have died had that referral been accepted.
But he was sufficiently concerned about the weight given to the referring mental health professional’s assessment that Manx Care and/or the DHSC must now respond.
That’s important.
Because Philip’s story challenges one of our favourite suicide-awareness messages.
Reach out.
He did.
His mum did.
A mental health professional did on his behalf.
So suicide prevention cannot end with persuading people to ask for help.
We also have to examine what happens after they ask.
Physical illness belongs in this conversation too. Chronic pain, disability, terminal illness and the loss of independence or identity that can accompany serious illness can fundamentally change somebody’s relationship with life. Sometimes there is no villain and no institutional failure. There is simply suffering. In other cases, illness creates vulnerability upon which isolation, dependency, abuse or exploitation can build.
We’ve seen this before
Philip isn’t the first Isle of Man death to raise questions about the space between recognised risk and effective protection.
BTJ has been examining published inquest findings spanning many years.
We’ve found previous attempts, expressed suicidal thoughts, worried relatives, professional involvement, psychiatric admission, addiction, trauma, family histories of suicide, fragmented assessments, failures to follow policies, information that wasn’t connected and people who appeared calm shortly before dying.
In some cases coroners found neglect or systemic failure.
In others shortcomings were identified but weren’t found to have caused the death.
The circumstances are different.
The recurring question isn’t.
Who had the whole picture?
Our own work has reached the same conclusion again and again:
Everybody owns their individual event. Nobody owns the pathway.
That’s the disconnected helm.
Police have their event.
Mental health has theirs.
The GP has theirs.
Safeguarding has theirs.
The school has theirs.
The employer has theirs.
The family has the things they’ve witnessed at home.
Each may be looking perfectly properly at the piece in front of them.
Yet a human life isn’t lived in separate organisational files.
Thresholds don’t experience cumulative harm. People do.
This is where safeguarding can go badly wrong.
One incident doesn’t meet the threshold.
Neither does the next.
Or the next.
The school sees bullying.
Police see an incident.
The GP sees anxiety.
Mental health sees depression.
Social care sees family difficulty.
The bank sees unusual transactions.
The employer sees deteriorating performance.
The family sees somebody changing before their eyes.
Individually, each piece might appear manageable.
Put them on the table together and sometimes you’re looking at an entirely different person and an entirely different level of risk.
That’s why one of the simplest principles behind our work is:
Zoom out before you zoom in.
My book The Disconnected Helm begins from exactly that premise: we record deaths, incidents, complaints and safeguarding referrals but give far less attention to the decisions, warnings and missed opportunities that came beforehand.
Coercive control changes the suicide conversation
This is an area we can no longer afford to treat as fringe thinking.
Domestic abuse isn’t only physical violence.
Coercive control can systematically remove somebody’s independence, confidence, money, relationships, reputation and belief that escape is possible.
Isolation.
Monitoring.
Threats.
Humiliation.
Financial control.
Gaslighting.
Post-separation harassment.
Technology-facilitated abuse.
Using children.
Using professionals.
Controlling the narrative other people hear about the victim.
None of those necessarily looks like the ‘big incident’ systems are waiting for.
Together they can become somebody’s entire world.
Scotland has now gone considerably further in recognising this. Since April 2026 it has had a statutory Domestic Homicide and Suicide Review model for deaths where domestic abuse is known or suspected. Its guidance specifically tells reviewers examining domestic-abuse-related suicide to consider cumulative trauma, coercive control, fear, isolation, financial abuse, stalking, threats, technology-facilitated abuse and manipulation of services.
Think about what that means.
They’re reconstructing the pathway.
Not simply recording the ending.
And sometimes the first story isn’t the whole story
This matters particularly in unexpected deaths.
At BTJ we’ve worked with a family who aren’t asking us to accept their interpretation of their loved one’s death.
They’re asking questions.
That’s different.
Questions about the evidence.
Questions about the timeline.
Questions about toxicology.
Questions about what was preserved.
Questions about the narrative surrounding the death.
Questions about whether everything that should have been examined actually was.
I’m deliberately not naming that family.
But their experience has reinforced something fundamental for me.
A suicide conclusion should never prevent questions being asked about the pathway to it.
Mental illness isn’t proof of suicide.
Domestic abuse isn’t proof that somebody else killed them.
A note isn’t automatically the whole story.
An overdose isn’t automatically intentional.
Addiction isn’t an explanation for everything.
A troubled history shouldn’t close an investigation.
Labels aren’t investigations.
Our recent BTJ paper on unexpected deaths makes exactly that distinction: the physical mechanism of death can tell us how somebody died without necessarily explaining the circumstances that led there.
Children are walking pathways too
Perhaps nowhere is this more urgent than with children.
We talk about online bullying as though the internet exists somewhere outside their lives.
It doesn’t.
The bully can now come home with them.
Into the bedroom.
Onto the phone.
At midnight.
At 3am.
Into every place that should once have been safe.
Then add grooming.
A vulnerable child is noticed.
Attention becomes friendship.
Friendship becomes dependency.
Dependency becomes secrecy.
Secrecy becomes isolation.
Isolation becomes control.
Control becomes threats.
Drugs may enter the picture.
Sexual exploitation may enter it.
Crime may enter it.
Suddenly everybody sees a ‘difficult teenager’.
Police see offending.
School sees absence.
Parents see aggression.
Health sees substance misuse.
Social services see non-engagement.
Nobody necessarily sees the child who was groomed at the beginning.
Again:
What happened before that?
Addiction has a pathway too
I’ve become increasingly uncomfortable with the way society sometimes talks about addiction.
‘Drug addict.’
‘Alcoholic.’
‘Choice.’
‘They won’t engage.’
Perhaps.
Personal responsibility matters. People can harm others through addiction and we shouldn’t romanticise it.
There are also people who repeatedly reject help and people who manipulate systems. Recognising vulnerability doesn’t require us to pretend otherwise.
But addiction can also sit at the end of another pathway.
Childhood trauma.
Abuse.
Pain.
Bereavement.
Homelessness.
Grooming.
Mental illness.
Self-medication.
Isolation.
Then addiction itself creates another layer of stigma and vulnerability.
If we only investigate the drug, we’ve started halfway through the story.
The same principle reaches older people
Elder financial abuse may seem miles away from Suicide Awareness Month.
It isn’t always.
Imagine gradually losing control of your money.
Then your home.
Then contact with family.
Then your independence.
Perhaps somebody is telling professionals you’re confused.
Difficult.
Forgetful.
Paranoid.
Perhaps your concerns are interpreted through age, dementia or declining capacity.
Imagine how hopeless life could become.
Coercive control doesn’t suddenly stop being coercive control because the victim turns 70.
Nor should psychological harm disappear from our thinking because the abuse is primarily financial.
Then there’s the power of the narrative
This brings us to something society is only beginning to understand.
A person doesn’t need to be physically imprisoned to feel there is nowhere left to go.
Reputation can become a prison too.
We’ve recently watched the extraordinary public story surrounding Professor Jason Arday.
Whatever ultimately emerges about the controversies surrounding his work, his death should force us to think seriously about the human being inside a modern reputational storm.
Allegation.
Publication.
Repetition.
Social media.
Comment.
Amplification.
More repetition.
Perceived fact.
Collective judgement.
The internet didn’t invent this behaviour.
It industrialised it.
My stepfather experienced something recognisably similar in 1995.
No algorithms.
Just people.
Gossip got an algorithm.
And now a narrative can travel around the world before the person at the centre of it has even worked out how to respond.
Due process was designed for allegations.
Social media was designed for engagement.
Those two clocks don’t run at remotely the same speed.
Whistleblowers can experience another version
We’ve also encountered people who challenge institutions.
They raise something uncomfortable.
Initially they’re the employee, professional, campaigner or family member raising a concern.
Then something changes.
Their conduct becomes the issue.
Their personality.
Their tone.
Their mental health.
Their credibility.
Their motivation.
Sometimes there may be perfectly legitimate concerns about a complainant or whistleblower.
Sometimes there aren’t.
That’s precisely why we need evidence rather than labels.
Because institutional reputation can be extraordinarily powerful and the psychological impact of fighting a large organisation, particularly while being disbelieved or publicly discredited, can be immense.
Again, don’t just investigate the final breakdown.
Investigate what happened before it.
And yes, sometimes people do ‘play the system’
We need to be grown-up enough to say this too.
Not every claim of distress is genuine.
Not every allegation is true.
Not every person presenting as vulnerable is incapable of manipulation.
Some people weaponise mental-health language.
Some weaponise safeguarding.
Some make false allegations.
Some manipulate professionals.
That reality isn’t a reason to dismiss everybody else.
It’s a reason to investigate properly.
We don’t improve safeguarding by automatically believing everything.
We don’t improve it by automatically disbelieving everything either.
We improve it through curiosity, evidence, corroboration and looking at the whole picture.
‘Attention seeking’ may be exactly the point
One phrase still bothers me enormously.
Attention seeking.
Sometimes somebody is seeking attention.
Perhaps we should ask why.
A person saying ‘I can’t cope’ may actually be seeking attention because they desperately need somebody to pay attention.
A teenager harming themselves doesn’t become less vulnerable because somebody thinks they’re being dramatic.
A person repeatedly attending crisis services doesn’t become safe because professionals have seen them before.
Familiarity can be dangerous.
Yesterday’s ‘frequent attender’ can still become tomorrow’s inquest.
Suicide prevention has to move upstream
Of course we need crisis teams.
Helplines.
Counselling.
Psychiatry.
Medication.
Peer support.
Good GPs.
Community support.
We need people to talk.
But if Suicide Awareness Month becomes solely about encouraging distressed people to present themselves to services, we’re still waiting until somebody is drowning before discussing why they ended up in the water.
Real prevention also means tackling:
coercive control and domestic abuse
bullying and online abuse
childhood trauma
grooming and exploitation
addiction pathways
financial abuse
loneliness and bereavement
workplace bullying
institutional retaliation
reputational destruction
and the gaps between the organisations supposedly protecting us.
Because sometimes the crisis is the end of a very long story.
Every story begins long before the ending
This is probably the biggest lesson I’ve learned through Bridge to Justice.
I’ve investigated what initially looked like completely different subjects.
Domestic abuse.
Suicide.
Mental health.
Elder financial abuse.
Capacity.
Safeguarding.
Addiction.
Professional accountability.
Unexpected deaths.
For years they looked like separate worlds.
They’re not.
Again and again, underneath them, I find the same thing.
A pathway.
Small events.
Warnings.
Changes.
People who noticed something.
Professionals who held one piece.
Families holding another.
Thresholds that weren’t quite met.
Information that didn’t travel.
A narrative that became accepted.
Opportunities that weren’t recognised until everyone looked backwards after the ending.
That’s why perhaps the most important question we can ask after a suicide isn’t simply:
Why did this person die?
It is:
What happened in this person’s life before they reached the point where death appeared to them to be the only way out?
Then:
Who knew?
What did they know?
What did the family know?
What did professionals know?
What wasn’t shared?
What was dismissed?
What was labelled?
What threshold wasn’t met?
Was coercive control considered?
Was trauma considered?
Was abuse considered?
Was somebody controlling the narrative?
Did the person ask for help?
What happened when they did?
And, most importantly:
What can we learn from this life that might help save the next?
That’s not about finding somebody to blame for every suicide.
Sometimes there may be nobody to blame.
Sometimes, despite enormous efforts, a death may genuinely have been impossible to predict or prevent.
It’s about refusing to treat suicide as though the final act explains the whole life.
It doesn’t.
Every person had a story.
Every person walked a path.
If we’re serious about suicide prevention, we need to start investigating the path, not just recording where it ended.
Because every story begins long before the ending.
How Bridge to Justice can help
At Bridge to Justice, we often become involved when the story is complicated, fragmented or simply doesn’t seem to make sense.
We can independently review records, evidence, timelines and professional involvement to help families understand the wider picture. That may include concerns around coercive control, domestic or financial abuse, safeguarding failures, institutional responses, unexplained or unexpected deaths and the circumstances leading to a suicide.
We can also help identify unanswered questions, gaps in evidence and information held across different organisations that may never have been considered together.
We are not a crisis or counselling service and we don’t replace the police, Coroner, healthcare professionals or legal advisers.