A coroner will write to health bosses in a bid to prevent more deaths after mental health staff were “too busy” to contact a grieving boyfriend later hit by a train.
Rachel Syed expressed concerns that mental health services did not have enough staff to contact Adam Howarth after an emergency referral.
Staff should have called him within four hours of receiving the referral at 2.58pm on June 27, but did not do so until 8.10am the next day.
Adam, 29, was fatally injured that day when he stepped onto the tracks at Wigan North Western railway station and was hit by a train.
An inquest into Adam’s death was held at Bolton Coroner’s Court, shortly after an inquiry into the death of his girlfriend Chloe Spencer, 27.
She died by hanging on June 22, just six days before Adam’s death.
It is believed she had sent a text message to Adam two hours before her body was found.
The coroner heard the pair started dating in July last year, but their relationship had its “ups and downs”.
Adam’s mother Ann Lloyd said he was “heartbroken” by Chloe’s death and wanted to carry the coffin at her funeral.
He was said to be struggling and had an appointment with North West Boroughs Healthcare NHS Foundation Trust on June 27.
His mother described it as a “mental health assessment” but a counsellor told the inquest it was to see if he would benefit from therapy.
Adam said he had felt suicidal but could keep himself safe and wanted to go to Chloe’s funeral, the inquest heard.
The counsellor said he felt safe to leave and she told him someone would contact him in three to four hours.
But Christopher Peake, investigations lead at North West Boroughs, told the hearing: “The assessment team were unable to respond to a number of emergencies that day, including Adam, due to staff sickness. The assessment team required more time to deal with the established emergencies. The crisis team and assessment team struggled to manage the demand. On the day in question the volume of referrals of emergencies that were executed was affected as the team were affected by staff sickness.”
Miss Syed said: “I am astounded an agency can turn up to an inquest and say they are too busy and don’t have the staff to process life and death referrals. It is not acceptable. It’s hard to understand why you hadn’t got a contingency plan in place on 27 June.”
David Hindley, from North West Boroughs, said: “There is a lot of trouble trying to cope with the volume of referrals, especially a lot of complex referrals in the Wigan area. We are asking for staff to work overtime shifts but we have only got so many staff. We let Adam down, we weren’t able to meet his needs. I’m so sorry.
“Going forward we are transferring the crisis team to 24/7 and the assessment team will be working at the Royal Albert from January. We need to make sure we’ve got the right staff in the right places. We are looking for staff to cover that particular team. We want to give the best service possible. We have various recruitment drives. The whole system, in my opinion, is struggling to manage. It’s a wider issue.”
Recording a suicide conclusion, Miss Syed said: “I am issuing a regulation 28 report to North West Boroughs Healthcare. I am deeply concerned about the evidence in relation to the lack of contingency planning for dealing with periods of high demand. I hope my comments about budgeting and the lack of contingency planning will be made aware to the senior planning and management team.”
She passed on her “sincere heartfelt condolences” to Adam’s family, describing the warehouse worker as “a truly delightful young man”.
After the hearing, Gail Briers, chief nurse and deputy chief executive at North West Boroughs, said: “I would like to offer my sincere condolences to Adam’s family. I’m so sorry we did not provide support for Adam quickly enough when he was in crisis.
“We are aware our Wigan assessment service is struggling to meet the high demand for mental health assessments and we have been working with partners across the borough to develop robust plans to address this.
“These will be in place in January.”
If you are struggling to cope, Samaritans are available 24 hours a day by calling 116 123.