A 22-year-old took his own life after being given a gravestone reference during a therapy session, a court heard.
Benjamin Davis, also known as Binyomin Chaim Davis, took his own life only a few months after the session, having "never got over that experience," his dad said.
The young man was found at his home in Prestwich, Greater Manchester, and died at Salford Royal Hospital in November five days later.
An inquest was held at Bolton Coroner's Court on Wednesday where private counsellor Avremi Rosenberg admitted that he should have used different wording in his session with Benjamin, who was 21 at the time.
He also accepted that the language was "inappropriate", reports Manchester Evening News.
Mr Davis, Benjamin's dad, told the court that his son had a "charming smile" and was a "special person."
Speaking at the inquest, he said: “We really miss him. He had a kind nature with a charming smile. He was a great student, he enjoyed photography, walking, and spending time with his family. He was a real pleasure to be with and he’s missed by family and friends.”
Despite his academic prowess, Benjamin struggled initially to fit in at school but eventually made a close knit group of friends. His challenges at school meant Benjamin was diagnosed with depression and anxiety in 2018, Mr Davis continued.
The youngster was also diagnosed with autism in 2021, assistant coroner Rachel Syed heard. After this diagnosis, Benjamin had five counselling sessions with Mr Rosenberg in spring last year.
And it was during these sessions in which Mr Rosenberg referenced a gravestone, Mr Davis said.
He added: "I asked Mr Rosenberg about it and he confirmed he did [say it].
"When asked why used the imagery, Mr Rosenberg said he said 'in the context that his autism diagnosis was… part of him but not all of him'."
He added: “Benjamin approached me because he knew I was a counsellor with experience with working with people on the autism spectrum. In hindsight, this would have been better dealt with by the NHS. I did apologise to Benjamin for the way it came over.
"It was definitely not said in a blunt way. It was very much in the context that his autism diagnosis was very important and it was part of him but not all of him, and in that context what would be written on his gravestone. In the future whatever I can do to help you to come to terms about what has happened, I would properly arrange it. I express my sincerest, sincerest condolences."
When asked by the coroner if his choice of words was "inappropriate", Mr Rosenberg replied: "Definitely, yes."
Ms Syed said at the conclusion of the hearing that she would be writing a letter of concern to Mr Rosenberg’s organisation.
She also will be writing letters of concern to Benjamin’s GP surgery Whittaker Lane Medical Centre and Greater Manchester Mental Health Trust (GMMH).
The coroner explained: "A formal letter of concern will be written to the GP, GMMH, and the private organisation, highlighting the need to ensure a more collaborative working approach between these organisations and sharing information such as diagnoses of autism.
"I will also reference the need to have more training on autism as a condition."
Earlier in the hearing, Benjamin’s GP in the final months of his life, Dr Rebecca-Ann Sheppard-Hickey, said she could not find a record of a formal autism diagnosis in his notes.
Dr Ruth Watson, from GMMH, carried out an internal review of Benjamin’s care, and also admitted mistakes were made with clinical staff now receiving more in-depth training on autism.
She said: "The main focus is that staff need additional training on autism. It is going to be added to our clinical risk training as an additional focus point."
Dr Watson did however add it was "difficult to say" if Benjamin’s death was preventable from the perspective of mental health services, as his last involvement with the service came around two months before his passing.
Recording a verdict of suicide, Ms Syed confirmed that Benjamin’s medical cause of death was hypoxic ischemic encephalopathy.
She concluded: "I am sadly satisfied to the relevant legal threshold [Benjamin] intended to take his own life. I am therefore in law required to record a verdict of suicide. I hope you can focus on the wonderful memories you have of Benjamin."
The Samaritans is available 24/7 if you need to talk. You can contact them for free by calling 116 123, email jo@samaritans.org or head to the website to find your nearest branch. You matter.
