Lessons learned following tragic death of Wigan man after mental health battle

Mark Fleming’s body was found by his wife Paula in the garage at their home in Billinge, an inquest at Bolton Coroner’s Court heard.

The 47-year-old woke up at 5am on February 6 to go to work as a warehouse operative at a supermarket distribution centre, but his wife became concerned when he did not return home.

She discovered he had not gone to work and began to look for him, before finding his body.

The inquest heard the couple got married in 2017, but Mrs Fleming said he started to develop problems with his mental health, was unhappy at work and his behaviour changed.

There were also issues with his relationships with family and friends, the inquest heard.

A report from Mr Fleming’s GP Dr Anna Newton, from Garswood Surgery, said he first complained of low mood in 2017, thought to be an “acute stress reaction” to several factors. He completed a course of therapy and saw an improvement.

Mr and Mrs Fleming saw the GP in July 2018 when his mood had deteriorated. He started to take anti-depressants and was referred for psychotherapy.

The inquest heard he had regular GP appointments from November 2019 to June 2020, when his mood remained “variable” due to ongoing stress.

He changed anti-depressant in June 2020 and he expressed thoughts of suicide that October. He was seen by the mental health team and discharged after showing improvement.

But by March 2021 his mental health deteriorated again and he was diagnosed with emotionally unstable personality disorder. He was discharged to his GP for medication and talking therapy.

The situation worsened in January 2022 and an urgent referral to the mental health team was made. It was suggested he try another anti-depressant and Dr Newton arranged an appointment with a mental health practitioner.

A report from senior mental health nurse practitioner Kate McGlue said Mrs Fleming stated her husband had been in crisis for a few days and she feared he would kill her or himself.

Mr Fleming said he felt better and had no suicidal ideations or thoughts of harming others. He was referred to the GP to discuss medication and therapy.

At an appointment on February 3, Mr Fleming was referred for therapy for emotionally unstable personality disorder, but was upset the assessment process would begin again, the inquest heard.

After Mr Fleming’s death, an investigation into his care was carried out by Mersey Care NHS Foundation Trust.

Diane Warburton, assistant director of nursing for urgent care services, said three main areas of learning were found. These surrounded the quality of documentation from the phone assessment of Mr Fleming by Ms McGlue; Mr Fleming was not directly asked if he had suicidal thoughts during the final appointment; and a duty of candour letter telling his family there would be an investigation contained inaccuracies.

Although outside the scope of the investigation, she said they could have considered speaking to Mr Fleming’s family after his diagnosis.

She also apologised for errors in the investigation report, highlighted by Mr Fleming’s wife and his sister.

Coroner Peter Sigee said he did not believe these issues affected the outcome and he recorded that Mr Fleming died by suicide.

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