Wigan mental health staff 'missed opportunities' to help dad in the hours before he died

Darren McHugh, 39, was found dead at his home in Leigh on June 12, just hours after telling staff at Wigan Infirmary that he needed inpatient care.

He reported hearing voices, was paranoid about going home as he thought a neighbour wanted to kill him and believed previous psychosis had returned. He had also taken an overdose a week earlier.

Mr McHugh saw mental health professionals at Atherleigh Park on June 11 and went straight to the infirmary afterwards, believing he was waiting for a bed.

But an inquest at Bolton Coroner’s Court heard staff from Greater Manchester Mental Health NHS Foundation Trust did not believe he had psychosis or needed to be admitted and instead offered treatment at home, which he declined.

The care provided to Mr McHugh was examined in a concise serious incident review, which raised several action points.

They were: a learning event for team managers and senior leaders to discuss the case; away days for urgent care staff to look at crisis planning and clinical risk training; the supervisor of a staff member who assessed Mr McHugh will review documentation from that; and a trusted assessor scheme will be adopted across Wigan, so patients do not have repeated assessments.

Angela Calland, operational manager for urgent care, said the trust was looking at whether staff could contact patients’ families to gather information about them, even without consent.

She explained written information about their care, including their next appointment and service contact details, was given to patients – despite Mr McHugh not being clear on when his next appointment would be.

Coroner Peter Sigee questioned Mrs Calland on the decision to offer care through the home-based treatment team.

She said: “From the documentation that I have had access to and I have read and considered fully, it was clearly documented that at the time Mr McHugh had capacity and the practitioners felt, in line with least restrictive principles, that the home-based treatment team was an offer of a service that could support someone at home as an alternative to admission.”

Mrs Calland said that could have provided up to three visits a day and support from experts, and did not rule out him being admitted in future.

Mr McHugh’s cause of death was hanging and Mr Sigee recorded he died by suicide.

He said: “There were missed opportunities for mental health services to: one, communicate more effectively both within their different teams and with Mr McHugh and his family; and two, more thoroughly assess the risk that Mr McHugh may harm himself following his attempted overdose on June 6, 2022.

"It cannot be determined that such additional communication and/or assessment as may reasonably have been provided would have one, altered the decision by mental health services not to offer Mr McHugh inpatient mental health care before June 12, 2022; and/or two, led to additional mental health care being provided to Mr McHugh which would have enabled his death on June 12, 2022 to be avoided.”

Mr Sigee considered neglect, but did not find evidence meeting a test set out by the Court of Appeal.

If you need to speak to someone, call Samaritans at any time on 116 123.