Coroner's concerns about mental health services after Wigan woman's drugs death

Caroline Farrington had consumed her prescription medications, along with cocaine and diazepam, before she died on August 17 at her home in Scholes.

But an inquest at Bolton Coroner’s Court heard she did not overdose on any of the drugs, instead suffering respiratory failure from the combined effects of them.

She also had diabetes mellitus and cirrhosis of the liver, which consultant histopathologist Dr Naveen Sharma, who carried out a post-mortem examination, explained would make it more difficult for her body to process the drugs.

The court heard Miss Farrington had a happy childhood in Chorley and worked for M&S after leaving school, with her parents describing her as “very modest” and “well liked”.

But she started taking drugs when she was 18, after forming a relationship and making friends with other drug users.

She lost her job and her life began to decline, so her family moved out of the area in an attempt to overcome the problems.

Miss Farrington’s partner died in 2018 and she suffered from pain in her legs and diabetes, which led to both of her legs being amputated below the knees to save her life in 2019.

She needed to use a wheelchair and spent a long time in hospital, before going to live in a one-storey council-owned bungalow in Scholes.

Her parents visited every day to support her, despite living 10 miles away, but she was “very lonely” and they were concerned that she was letting people into the house who were taking advantage of her.

The court heard she was befriended by people who knew she had a history of using drugs and returned to taking them, while people stole things from her and her windows were smashed by a thief who took her television.

But Miss Farrington had received support from drug and alcohol service We Are With You for several years, engaged “well” and was prescribed methadone to help her withdraw from heroin.

Several drug screens between 2018 and 2022 showed she was complying, but there were occasionally times she took illicit substances, the court heard.

Kevin Hobin, team leader for We Are With You, said tolerance to drugs can drop “very, very quickly”, something people who have been using them for a long time may not realise.

Miss Farrington went to an appointment with the service at Coops on August 16, but the worker she met was concerned that she appeared to be sedated and that increased during the session, so he brought it to an end.

He planned to bring together several organisations so they could support Miss Farrington with her physical and mental health, as well as substance misuse.

Her father Colin Farrington drove her home, describing her as “tired” and “a bit delirious”, but said she would often sleep at that time of day and he was not concerned.

He helped her into bed, before leaving to go home.

But when he returned the next morning, Mr Farrington found his daughter in the same position and unresponsive.

Emergency services were called but the 47-year-old was confirmed to have died.

Coroner Prof Dr Alan Walsh recorded she died “as a consequence of both prescribed and illicit drugs, contributed to by naturally occurring disease”.

He said: “I accept that this was not a suicide, this was not something she intended and it is likely that she wouldn’t have known that combination would have led to her death.”

Prof Dr Walsh had concerns about the mental health support given to Miss Farrington in the months before she died.

She was discharged from services after failing to take part in a review five times, asking for it to be held another time, rescheduled for when her parents were there or not answering the phone call.

He said staff should have contacted her father to look into this, as he had already been in touch and they had “inferred consent” to speak to him.

Miss Farrington’s parents said a member of staff visited after her death and confirmed this should have been done, but it was not included in a report produced by Greater Manchester Mental Health NHS Foundation Trust.

Prof Dr Walsh was told changes had since been made and staff do now engage more with families when consent is given, with a weekly quality assurance audit carried out to check on this.

The coroner also expressed dismay that he had not been told about the report produced after Miss Farrington’s death, after he requested information from the trust as part of his inquiries.

He plans to change the questions he asks organisations in future to ensure they provide details of such investigations.

While two “lessons learned” were identified in the report by the trust, operational manager of community services Andrew Lakin said these involved administration and system processes.

Prof Dr Alan Walsh concluded that he believed mental health staff should have contacted Miss Farrington’s father about the review, but he was satisfied that systems are now in place to contact loved ones and he did not think it would have changed the outcome for her.

He praised her parents for the support they gave to Miss Farrington.

“I am truly very sorry to Caroline because of the way that her life was destroyed and sadly to the both of you, who could not have done more,” he said.