Coroner slams health service

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MENTAL health services in Wigan have been slammed after a pensioner suffering from dementia was deemed to have been unlawfully killed by her husband, who then took his own life.

An inquest in Bolton into the deaths of pensioners Jean and John Darbyshire ruled that 70-year-old Mrs Darbyshire was strangled by her mentally-ill, 71-year-old husband, before he hanged himself.

The 5 Boroughs Partnership, NHS Foundation Trust and Wigan Council was criticised by coroner Jennifer Leeming in her summing up, leading her to take the rare step of making a report to both the trust and the council to review employment services in light of the couple’s deaths. Over six days, the hearing was told how Mr and Mrs Darbyshire were being cared for by community mental health teams, but a catalogue of errors led to vital warning signs being missed by carers.

The inquest heard how Mrs Darbyshire was taken into care after an alleged assault by her husband, in October 2008.

Around the same time, Mr Darbyshire was taken into the Holdenbrook Unit, at Leigh Infirmary.

However, the pair were reunited in their home after Mrs Darbyshire asked to return home, and Mr Darbyshire was allowed to also return home, after being assessed by mental health staff during short leave periods.

Over the coming months, the court heard Mrs Darbyshire told carers she was “terrified” of her husband’s mood swings, and that Mr Darbyshire was aggressive and had started to drink more.

It transpired that he stopped receiving mental health care visits after his care co-ordinator left her post-and he cancelled his appointments with his next care worker, unbeknown to the care workers looking after his wife.

The pair were found on September 10, 2009 in their home on Whiteside Avenue, Hindley, by their son, David, who had to break in, after social workers had not heard from them in a few days.

A forensic pathologist told the court she believed Mr Darbyshire strangled his wife, before hanging himself.

Delivering her verdicts, the coroner, Jennifer Leeming, said: “John Darbyshire took his own life while the balance of his mind was disabled by mental illness.

“Under the care of community mental health teams, he had not been appropriately monitored, nor had the risk of harm to himself or to others been appropriately assessed.

“Jean Darbyshire was unlawfully killed, and died of ligature strangulation.

She was also under the care of community mental health teams, and her risk of harm had not been appropriately assessed.

“Under rule 43 of the Coroners’ Rules, I will be making a report to Wigan Council and the 5 Boroughs Trust to review their processes, to see if it is necessary to make sure employment processes, whereby concerns are reported to an unqualified worker, must be reported to an appropriate qualified member of staff.”

Following the hearing, a spokesman for 5 Boroughs Trust said: “We would once again like to express our sincere condolences to the family of Mr and Mrs Darbyshire.

“The trust has taken this tragic incident extremely seriously, and as the coroner noted, work is already under way to address the issues identified by the inquest.“

The Darbyshire family did not want to comment on the outcome of the inquest