Tragic death of Wigan man two days after leaving mental health hospital

Phillip Mangnall, 33, had spent six weeks at The Priory in Altrincham with schizoaffective disorder - a combination of schizophrenia and a mood disorder.

He was admitted in July after an overdose of heroin, codeine and anti-depressant mirtazapine, and concerns he was at risk of suicide.

An inquest at Bolton Coroner’s Court this week heard changes to his medication were making a difference and he was due to be discharged from The Priory on September 6.

But Mr Mangnall, from Bickershaw, asked to leave on September 2, saying he was worried about his mother as she was having tests for cancer - something she told the inquest was not true.

He was discharged that day and given enough medication for five days, until he could see his GP.

The inquest heard staff at The Priory did not follow procedures such as informing his mother he was leaving and arranging an appointment within 72 hours with the mental health team in Wigan.

Mr Mangnall went to stay at his mother Kathleen Hoare’s house in Ince.

He went to his GP practice for a repeat prescription the next day before bumping into Hayley Ainscough, clinical lead for the recovery team in Wigan, as she arrived at work at Claire House.

She told the inquest she was “surprised” to see him, as she did not know he had been discharged, and invited him in for a 72-hour follow-up appointment.

She said Mr Mangnall appeared to be “really healthy”, had gained weight, denied having psychotic symptoms and said he did not want to use illicit drugs anymore.

She phoned The Priory for a discharge summary.

Mr Mangnall and his mother spent the evening watching television until the early hours and fell asleep on sofas.

When she awoke at 7.45am, she found her son lying on the floor and called 999, but he was confirmed to have died.

Tests showed he had taken a combination of medication, cocaine, methadone and alcohol.

Most of the medication had been prescribed to him, but some had not, and the methadone belonged to his mother.

Levels of some drugs could not be established accurately, but police investigations suggested Mr Mangnall had taken five days’ worth of some medication in just 48 hours.

A post-mortem examination showed he had fatty liver disease, which may have made it more difficult for the liver to metabolise the drugs, leading to them building up in his body.

He also had left ventricular hypertrophy - thickening of the wall of the heart’s main pumping chamber - which can lead to cardiac arrest.

Consultant pathologist Dr Emil Salmo concluded he died from combined drug toxicity, exacerbated by fatty liver disease and left ventricular hypertrophy.

John Walsh, from Priory Hospital Cheadle Royal, told the inquest he carried out a review of Mr Mangnall’s care and found issues with his discharge.

Staff did not contact Ms Hoare or Ms Ainscough about the early discharge and did not make arrangements for a follow-up appointment.

He said there was a discharge checklist of everything that should be done and this was now being added to an electronic system across The Priory to ensure it was completed.

Coroner Catherine Cundy accepted The Priory recognised its errors and was taking action, and did not believe the discharge issues contributed to his death.

She did not believe Mr Mangnall intended to take his own life and recorded that it was a drug-related death.

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