Mental health services 'missed opportunities' to help Wigan man just days before he died

David Prescott, 34, died at his home in Ashton on May 18 and was described by his family as a “selfless person” and “talented artist”.

An inquest at Bolton Coroner’s Court heard he faced a mental health crisis on May 12 and told a GP at Bryn Street Surgery he had suicidal thoughts.

An urgent referral was made to mental health services and a telephone assessment led to an appointment with the urgent response team on May 15.

But staff at Greater Manchester Mental Health NHS Foundation Trust (GMMH) failed to follow protocol when he did not attend that appointment.

This included only minimal notes being made about his non-attendance, including nothing about what to do if he subsequently made contact with the service.

David did phone to ask when the appointment was, unaware he had missed it, but rather than this being escalated to a practitioner or line manager, he was sent a letter with another appointment scheduled for May 28.

The inquest heard an investigation found “missed opportunities” to help David, including reassessing his level of risk when he did not attend.

However, assistant coroner Stephen Teasdale said it was not possible to determine whether that played a role in his death.

He said: “It is unfortunate that the appointment on the 15th was not available to him. He was still willing to co-operate fully – I am satisfied of that because he rang services.

"I am satisfied that there is a procedure in place for those who do not attend appointments and in this particular case, procedure was not followed. As a result of the lack of following the procedure, there is a delay in making an alternative appointment, but I am unable to say the consequences of that particular delay and whether it affected the outcome or not.”

GMMH said it is now re-educating staff on the correct procedures and would be carrying out an audit to check on this.

The inquest heard David had a “multitude” of problems, including a history of illicit drug use, suicide attempts and financial worries.

He had been diagnosed with ADHD as an adult, but did not always take his medication.

David was admitted to A&E in February after taking an overdose of paracetamol and was supported by the home-based treatment team after discharge.

Apart from a relapse on March 20, when he went on a four-day cocaine binge, David made good progress and said he was no longer using drugs.

Dawn Senior, a senior nurse practitioner from the home-based treatment team, told the court David had short, medium and long-term goals when he was discharged from the service on April 21 and was keen to get more help from substance misuse service We Are With You and psychological therapy.

He reported feeling brighter in mood, having more energy and getting more enjoyment from life, including seeing friends again, riding his bike and working.

But David often went through cycles of feeling well, before relapsing and struggling.

On May 4, he had an appointment with We Are With You and spoke of cravings for cocaine, having not taken it for a few days, being in debt to drug dealers and not eating for several days as he did not have any food.

David then went to Bryn Street Surgery on May 12 reporting that he wanted to end his life and a GP asked for an emergency mental health assessment.

This had to be done within four hours, so David waited at the surgery and had an assessment by telephone.

It was decided he would see the urgent response team three days later and his GP was asked to prescribe a sleeping tablet, though concerns were raised about this in court as David had not been able to afford prescriptions.

David failed to attend the mental health appointment on May 15, with the practitioner unable to contact him by phone.

He did contact the service, but it was only two days later that a letter with a new date of May 28 was sent.

The inquest heard David was found unresponsive on May 18 at the rear of the home where he had moved just four weeks earlier.

Toxicology tests showed he had consumed cocaine, codeine and a prescribed anti-depressant at some point before he died.

Mr Teasdale recorded David died by suicide, saying he believed it was an “impulsive act”.

After the inquest, his family said: “David was a much-loved son and brother who was very well liked by all his friends and his work colleagues.

“He was a selfless person and would also always to try to help others despite his own struggles. He had a passion for his artwork and was a talented artist outside of work.

“David had a very good job as a senior engineering technician. This was a very technical job and due to his struggles with mental health, particularly ADHD, it was sometimes hard for him to concentrate on his work. Due to this he unfortunately started to self-medicate with cocaine to help him focus on his work. He never used cocaine as a party drug as is probably the norm, but simply to help him in his work.

“Unfortunately this worsened his mental health as he was never happy with himself for doing this and he suffered with dark thoughts as a result.

“We do feel he was let down by the Greater Manchester mental health trust who failed to follow set procedures when David needed help in the days before his death.

“Everyone who knew him is devastated by his death and we are coming to terms with the fact that a person who had so much potential and talent is no longer with us.”