A popular Wigan dad died by suicide after his mental health suddenly deteriorated, an inquest heard.
Lee Campbell, 32, sought urgent medical help after experiencing dark thoughts and expressing a desire to end his own life, Bolton Coroner’s Court was told.
He was admitted to Atherleigh Park in Leigh in the early hours of the morning after a mental health nurse deemed him to be at risk.
However, barely 12 hours later he told a doctor he had no suicidal thoughts and was keen to engage with services to get better.
He returned to the family home in Poolstock but vanished in his van after telling his parents he was going to a local shop.
But the inquest also heard that while he was still in hospital he was also searching for information about suicide online.
His body was found two days after he disappeared on August 18 with horrific wounds to his neck, wrists and arms.
North West Boroughs Healthcare NHS Foundation Trust came under severe scrutiny by assistant coroner Simon Nelson, with a number of failings being identified.
The Trust has issued a deep apology to Lee’s family for what went wrong.
The court heard Lee had never needed help with mental illness before as he worked as a self-employed plumber and was well known and liked around
Wigan but for around eight to 10 weeks before seeking his GP’s assistance had been in a very low mood following the breakdown of a relationship.
It was not the first time he had suffered personal heartache as his sister Phillipa was killed in a horror road smash nine years ago, but
the court concluded this had no relevance to his increasing difficulties in 2018.
Mental health nurse Charlene Dermott told the court that when she saw him on August 14 he seemed to be at risk of suicide.
However, after being admitted to Atherleigh Park he spoke very differently the following morning to Dr Edward Tyler, saying he had little thought of harming himself and was keen to discuss options for treatment.
Communication in the case was slammed by Mr Nelson, who said neither of Lee’s parents were properly told what was involved in escorted
leave and as she had previously attended it was his mother who should have been called to pick him up.
Nurses also should have discussed leaving hospital with his family and then reported any concerns back to senior consultants.
Under questioning Dr Tyler, who only joined the Trust the same month Lee was admitted, said he should have probed Lee’s mental state more closely given how different it was to the previous day’s assessment.
And his supervising consultant said that since then she had introduced a double assessment process whenever inexperienced junior doctors work with patients.
However, Mr Nelson said that was not enough and he wanted to see Trust-wide measures to ensure there could be no repeat of home leave going so tragically wrong in future.
Lee’s body was found in a secluded field close to a patch of woodland in a place the court heard was near where he played as a child.
It was found by his friend Shaun Willis, who had joined in a huge public search to find Lee but said he had a hunch he couldn’t explain telling him to go to that location.
Police investigations ruled out foul play. The medical cause of death was severe shock brought about by multiple lacerations.
Recording his conclusion of suicide, Mr Nelson said: “Lee was a man who had never previously threatened to self harm. For him things must have been really bad to have volunteered this information and taken his mum along to an urgent appointment.
“After he got to the hospital there is a complete change of presentation, which is unusual.
“Whether a more experienced clinician would have elicited different information from him we will never know.
“It was decided it would not be inappropriate for Lee to be afforded some leave. The views of the family should have been obtained and
weren’t and the implications should have been explained to them and weren’t.
“At home no-one would have any reason to believe he would embark on a course of action leading to the loss of his life.
“The Trust now has 28 days to report back, particularly on improvements for inexperienced clinicians in the hope these scenarios
can be avoided.
“Lee had achieved a great deal to be proud of in his relatively short life and I am sure he will be remembered with great affection as a
loving, caring individual.”
Aferwards Lee’s cousin Gill Butler, speaking on behalf of the family, said: “He had such a big impact on everybody who he met and no-one
will ever forget him.
“He was a genuinely great guy, beautiful on the inside and outside, a wonderful person and fantastic father.
“We hope the recommendations made by the coroner about the failings regarding junior doctors mean lessons will be learned for the future to stop other families going through what we are going through.
“It’s too late for us but hopefully it will help other families.”
The Trust said it was sorry for its shortcomings in Lee’s care.
Gail Briers, chief Nurse and deputy chief executive, said: “We offer our sincere condolences to the family of Lee Campbell for their loss.
“Following Mr Campbell’s death, we launched a serious incident investigation to thoroughly examine the care and support he received from our Trust.
“This investigation highlighted that Lee did not receive the standard of care we aim to provide and identified a lack of communication with
Lee’s family. We apologise unreservedly for this.
“As a result of this comprehensive investigation, we have made changes to enhance the care given to future patients and have committed to updating Lee’s family on action taken.
“We have discussed this case with staff across the Trust and have reiterated the importance of fully engaging with family members regarding all aspects of patient care, including requests for leave.
“These improvements will continue to strengthen the quality of care provided by our Trust.”
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