The suicide of a Wigan millionaire businessman’s wife sparked a radical overhaul of the way mental health assessments are conducted.
Sharon Haliwell took her own life at her Wigan home last April after with an addiction to sleeping pills, a coroner ruled.
The 48-year-old had also suffered abuse at the hands of her violent husband, Darren.
But Prof Jennifer Leeming, senior coroner for Manchester West, was concerned there was a lack of communication between different teams working for North West Boroughs NHS Foundation trust.
At her inquest, Mr Haliwell questioned at her inquest in August why she was not considered to be a "high risk" case, after she had spoken previously about having suicidal tendencies to two different services, less than a fortnight apart.
In a letter to the coroner Simon Barber, NWB’s chief executive, said a number of attempts had been made to address "connectivity issues" between different teams within the mental health trust.
He confirmed that staff from their Improving Access to Psychological Therapies (IAPT) team had been given training on recognising when patients had been subject to clinical intervention. And while he said it was not possible to fully integrate two patient information systems but work was ongoing to ‘flag up’ when a patient was known to be receiving assistance from a second trust team.
Mr Barber added: "In addition to this, the trust will amend all appropriate standard operating procedures by March 2018 to ensure that where clinicians identify a red flag alert, they contact the relevant clinical team and ensure that they have all the clinical information they require in relation to risk and ongoing treatment plans."
Prof Leeming was told that Mrs Haliwell, of Manse Gardens, Worsley Mesnes, had undergone a triage process with the IAPT team on February 7, after making an attempt on her own life, which indicated she remained at risk of suicide.
The inquest heard she also underwent a second mental health assessment on February 18, which came to similar conclusions. But due to an error she was not referred for counselling by an advanced nurse practitioner.
Issuing a prevention of death notice to NWB, the coroner said while she was satisfied some improvements had been made, she was still concerned about communications issues within the trust.
Mrs Haliwell was found dead at her home the following April, after family members had become concerned for her welfare.
"How big a risk does someone have to be before something is done?" Mr Haliwell told the hearing.
She also attended for sessions with drugs recovery charity Addaction but staff there said their involvement ended when she claimed she no longer abused sleeping pills.