A coroner conducting the inquest into the death of a troubled Wigan man has criticised alcohol and drug treatment services for poor-quality record keeping.
Assistant coroner Sarah Watson said Addaction’s notes of conversations with David Caffrey and his mum Karen were not detailed enough for her to fully look into the family’s concerns about his care.
David, from Aspull, was found hanged in woodland near his home on February 2 and his death was recorded as a suicide at Bolton Coroner’s Court.
The court heard the 39-year-old had battled mental health problems for around two decades and was diagnosed with psychosis but alcohol misuse made his symptoms worse.
Mrs Caffrey, of St David’s Crescent, told the court she was alarmed Addaction staff had recommended David carried on drinking alcohol when they visited in December 2016 as he had recently been in hospital with renal failure.
However, Clare Pearson from Addaction said this happened at a later meeting and was only about managing his condition if he experienced withdrawal from starting and stopping drinking.
I’m concerned that the notes given by Addaction are quite vague. I don’t know how the conversation developed, it is one person’s word against another’s.Sarah Watson
Ms Watson said: “I’m concerned that the notes given by Addaction are quite vague. I don’t know how the conversation developed, it is one person’s word against another’s.
“There could have been more depth and detail to the note-taking, especially as it was raised at the time as a concern by the family.”
The court heard David had begun working as a civil engineer and got qualifications from college but had to leave his job as his mental illness worsened.
Mrs Caffrey said things had gone downhill about 18 months ago after a medication which kept his condition stable was suddenly withdrawn by the pharmaceutical firm.
The court was also told he had been hit hard by the death of his father Peter in 2009.
Mrs Caffrey said he suffered from paranoia and also heard voices, but health professionals said he was generally lucid and coherent at appointments, though his anxiety was notably worse when he had been drinking.
She also told the inquest she had repeatedly begged for her son to be sectioned.
The court heard that the day before he died David had been brought home drunk but did not bring his behaviour up or apologise for it when he woke the following morning.
He went out about 11am but returned and then asked Mrs Caffrey for some hosepipe, which she refused to give him. He sat in his car smoking in the afternoon for almost 90 minutes before driving off.
An investigation by the North West Boroughs NHS Foundation found minor mistakes in David’s care, such as him not always having a dedicated co-ordinator, but nothing that had an impact on the tragic outcome.
A police probe ruled out any suspicious circumstances.
Concluding the inquest, Ms Watson said it was clear David “had a very sharp mind” and was “a good son” when he was not drinking and offered her sincere condolences to the family.
Speaking after the hearing Mrs Caffrey still felt changes need to be made in mental illness treatment.
She said: “We were failed by everyone: the mental health team, the alcohol team. I expected the conclusion but still feel badly let down. We were begging them for help but no-one listened.
“The big step forward for mental health professionals would be if they listened to the families and relations.
“I just want to raise awareness now about mental illness. People need to talk about it openly, it shouldn’t be a deep dark secret.”