System failure rapped after deaths

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WIGAN’S mental health trust and council chiefs have admitted failing a Hindley couple who died in tragic circumstances.

John Darbyshire, 71, who had a history of mental health problems, strangled his wife Jean, 70, at their home on Whiteside Avenue, before killing himself in September 2009.

At an inquest into their deaths in 2011, coroner Jennifer Leeming called for an investigation into services at the 5 Boroughs Partnership Foundation Trust and Wigan Council.

Following their deaths, an investigation by the NHS found that there was a series of failures from both the mental health trust and Wigan Council that resulted in the deaths of the couple.

Mr and Mrs Darbyshire - who had been married for 50 years - were found dead at home by their son after nobody had been able to contact them for a couple of days.

This followed a year of blunders by both the 5 Boroughs and Wigan Council, in which Mr Darbyshire, who was known to suffer from depression, anxiety and delusional beliefs, exacerbated by alcohol abuse, was left as the main carer for his wife Jean, who also suffered from depression and anxiety as well as dementia.

Throughout this period, a series of errors, including mixed-up medical records, a lack of risk assessments and poor diagnoses culminated in the couple’s deaths.

An independent investigation by the Health and Social Care Advisory Service, which was published yesterday, found that a “failure to assess, monitor, manage and support Mr Darbyshire in the community led to his reaching a point of crisis which ultimately led to the death of both him and his wife”.

It went on to conclude that “The treating teams had the knowledge, the opportunity and the means to intervene but did not do so”.

The report went on to conclude that “Mrs Darbyshire was a vulnerable adult whose needs were not assessed or addressed appropriately”.

Both the 5 Boroughs and Wigan Council said yesterday that the investigation has led to widespread changes in how they care for people in the community, which they say will greatly reduce the chances of a similar incident occurring in the future.

Speaking at a press conference yesterday, Stuart Cowley, director of Adult Social Care and Health at Wigan CVouncil said: “I would like to offer our sincere apologies and condolences to the Darbyshire family. No family should have to go through the kind of distress a tragedy like this causes and we are deeply sorry.

“We reviewed all our procedures and also started working more directly with the trust’s mental health services. Wigan Council takes safeguarding vulnerable people very seriously. We deal with thousands of vulnerable adults on a daily basis and we will continue to work hard to make sure trhey receiove the support and protection they deserve.”

The investigation concluded that the couple were failed in 14 specific areas and said that “the investigation team came to the conclusion that Mr and Mrs Darbyshire received a poor level of care and treatment from the 5 Boroughs and Wigan Council” and that “both organisations should share responsibility jpointly.”

Gail Briers, Director of Nursing at the 5 Boiroughs said: “We are truly sorry and saddened by this incident, but we have learnt form this and have implemented significant imporvenments.”