A senior coroner has called for action after the death of a Wigan woman battling mental health issues

Micheala Finch, 59, was found unresponsive at her home in Ashton on August 3.

An inquest at Bolton Coroner's Court heard she died from combined drug toxicity, after an overdose of prescribed antidepressants.

Senior coroner Timothy Brennand concluded her intention was "unclear" as it happened during "a recent and acute deterioration of her mental health driven by emotional dysregulation, disordered thinking, impulsivity and relapse into recent self-induced intoxication with associated intentional non-fatal overdose".

He has written a Prevention of Future Deaths report highlighting concerns about her care and sent it to Greater Manchester Mental Health NHS Foundation Trust and Greater Manchester Integrated Care Partnership.

His report explains Ms Finch had mixed anxiety and depression with associated alcohol dependence syndrome, which was managed by addiction services, primary and secondary mental health services, and her GP.

But when she relapsed she experienced chronic alcohol misuse and inadvertent overdoses of prescribed medications.

Ms Finch had been suffering from anxiety and depression when she started drinking on July 26.

She went to Wigan Infirmary two days later after an overdose of sedative zolpidem and refused a full mental health assessment, but agreed to a community mental health team referral and discharged herself.

She returned later that day with a further deterioration in her mental health and intoxication.

She was referred to the mental health liaison team for suicidal ideation and deemed to have full capacity.

Mr Brennand wrote: "She disclosed involvement in a family incident leading to a safeguarding referral. However, her mental health deterioration, emotional dysregulation and irrational behaviour were not fully appreciated, being attributed instead to alcohol misuse.

"She was discharged with a conservative community‑based care plan and deemed not to meet the threshold for escalated home-based treatment. Whether this decision affected the outcome cannot be established."

Ms Finch was arrested on July 31, in response to the safeguarding alert, and released with a caution.

On August 3, after concerns for her welfare, relatives and emergency services found her collapsed at home.

Mr Brennand said issues were identified which meant there was a risk of future deaths "unless action is taken".

He said Ms Finch may have been suffering from a co‑occurring disorder, warranting more active treatment, escalation and a care co-ordinator.

He wrote: "A recovery worker stated that Wigan addiction services receive numerous referrals involving service users with mental health needs requiring a care programme approach. Mental health provision was insufficient for such patients, and addiction services were perceived as an interim holding place for individuals with complex or nuanced needs."

Neither a mental health clinician nor the author of a rapid review of care identified missed opportunities to appreciate her deterioration, potential for a co‑occurring diagnosis and need for home-based treatment team referral, he said.

Relatives raised "profound concerns" about Ms Finch's deteriorating mental state, but they were not passed to the clinician and communication was "sub-optimal".

Mr Brennand reported mental health staff said "funding issues" limited their ability to provide more community care for patients who did not qualify for inpatient assessment or home-based treatment team referral.

He also highlighted "a significant incidence of self‑harm or attempted self‑harm shortly after assessment and discharge from the mental health team" at Wigan Infirmary.