Coroner seeks changes at mental health hospital after Wigan dad's tragic death

Shaun Houghton, 35, went to Atherleigh Park in Leigh twice in November amid concerns for his mental health.

A resumed inquest at Bolton Coroner’s Court heard on the second occasion he left against medical advice – and was later found collapsed in the place where his sister died five years earlier.

A junior doctor who had spent just four months working in psychiatry spoke to Mr Houghton before he left, but did not refer to a senior colleague, which aligned with training he had received.

But a consultant on another ward said junior staff would speak to him before allowing a patient to leave and the court heard Greater Manchester Mental Health NHS Foundation Trust did not have a formal policy.

Coroner Prof Dr Alan Walsh issued a regulation 28 Prevention of Future Deaths report asking the trust to review its policy for self-discharge or discharges against medical advice and consider a written policy for all units, along with a check-list for staff.

He said: “I think it needs to formalise and it needs to formalise quickly.”

But he said it was “unclear” whether a referral to another doctor would have changed the outcome.

He also urged to trust to consider the medication available to patients who discharge themselves.

The inquest heard Mr Houghton, from Worsley Hall, had a history of mental illness, including ADHD, unstable personality disorder, anxiety, depression and mental health and behaviour disorder due to substance misuse.

He was admitted to Atherleigh Park’s Prospect ward on November 16, where he made progress and was discharged on November 25.

But three days later he told a mental health practitioner he feared he would “impulsively” end his life and his partner said she was struggling to care for him.

Mr Houghton returned to Atherleigh Park on November 28 and while he was unhappy about being on Sovereign ward this time, he agreed to stay and a care plan was produced on November 29.

But the following day he decided to leave and was driven home by his mother, who had arrived to visit him. Prof Dr Walsh said it was a “pity” hospital staff had not invited her inside to speak to Mr Houghton before he left.

In the early hours of December 1, his body was found at a memorial in Orrell for his 17-year-old sister Charlotte Guy, who died there in 2017.

The coroner recorded he died by hanging but his intentions were “unclear”.

After the hearing, Mr Houghton’s family said he worked hard as an electrician “to provide for his family, whom he loved unconditionally”.

He enjoyed tending to his allotment, going to the gym and food, while his mum remembers him as a keen rugby player in his youth and a “larger-than-life” member of the cadets.

They said: “A regulation 28 has been raised and we hope this will help pave a better process for discharging mental health patients in the future. We hope that this will not only prevent further deaths from occurring, but ensure patients and their families are always involved in decision-making, together, as a strong unit to tackle mental health conditions."