Wigan dad-of-four who took his own life 'probably believed he was going to be rescued', inquest hears

Neil Baggaley, 40, was a voluntary inpatient at Atherleigh Park in Leigh and had made the remark in a tearful final phone call to his nephew.

However, when Mr Baggaley's long-standing partner Joanne Lucas immediately tried to contact the hospital, no-one picked up the phone for around 20 minutes.

When she did get through and staff checked Mr Baggaley's private room, he was found unresponsive and rushed to Wigan Infirmary. Tragically he died early the following morning on July 27, 2022.

An inquest at Bolton Coroners' Court heard it was not clear whether the delay in answering the phone had made any difference to the outcome.

Nevertheless, the coroner called for phone-answering services at the mental health facility to be improved.

Mr Baggaley, who lived in Worsley Hall, was a fanatical Manchester United fan and dad of four children.

The inquest was told he had a difficult childhood and his mental health problems were exacerbated by the death from sepsis of his sister two years earlier, who had been "like a mother to him."

He suffered from type one diabetes, engaged in illicit drug use and drank heavily. Although he had made a number of previous attempts to take his own life, he had always flagged these up beforehand, which meant family members were able to step in and save him in time.

Coroner Prof Dr Alan Walsh heard that Mr Baggaley's suicide attempt at Atherleigh Park may have been another such "cry for help." Tragically on this occasion he was not discovered in time.

At the time of the incident, Mr Baggaley was awaiting sentence at court for a criminal matter. One of his bail conditions was that he could not reside at the home in Worsley Hall he shared with his partner and mother of his children Joanne, or see them.

This had caused him great distress and he was concerned about where he was going to live after he was declared medically fit for discharge from Atherleigh Park. He had been admitted a week previously as a voluntary inpatient after an insulin overdose.

Mr Baggaley had been out of the hospital for most of the day before his death.

On his return, he was breathalysed and found to be more than twice the drink-drive limit and "covered in soot" from helping to clean a fellow patient's fire-damaged house. However, over the next few hours, hospital staff reported that he seemed to be "in good spirits", associating with fellow patients and playing on his Nintendo.

Dr Walsh said his "major concern" had been the 20 minutes it had taken Mr Baggaley's partner to raise the alarm about his intentions later that evening. He was told the phone line went through to an office but it could not be heard ringing when staff were occupied on the ward.

He said: "The ability to answer phones is vitally important. Mr Baggaley probably believed he was going to be rescued, like he was saved previously.

"If that phone call had been answered, there was an opportunity to check on him much earlier than when he was found. Whether that would have changed the outcome is unknown."

Dr Walsh recorded the cause of death as hanging and concluded the death was a result of misadventure.

He added that he was "disappointed" the issue with phone calls being answered promptly at the hospital had still not been rectified 15 months after Mr Baggaley's death, and asked for an update on steps to improve communications by November 10.

He told Mr Baggaley's family, who were present at the hearing: "It's immensely sad that a man dies at the age of 40 in these circumstances, but my greatest sadness and sympathy is for the children, who he was clearly close to and missed very badly."He had a troubled life which started when he was a child. He had mental health issues before his relationship with Joanne Lucas started 18 years ago. The significant event was the death of his sister, which he failed to come to terms with and caused a flare-up of his emotions. He took actions against those he loved that got him into a mess.”Speaking after the hearing, Joanne’s sister Shereen said: "Neil was the kindest, most caring man you could ever meet. He loved his kids and his family. He was a father figure to his three nephews, who he adored like they were his own kids. His good friends thank him for the memories. He'll be very, very sadly missed."

In response to the concerns raised at the inquest, a spokesperson for Greater Manchester Mental Health NHS Foundation Trust said: “Our thoughts and heartfelt condolences are with Mr. Baggaley’s family and friends at this time.

“Following the incident, we have carried out an extensive investigation, which led to a comprehensive action plan to improve the telephone communication into our wards at Atherleigh Park and our care pathway for patients enhancing communication among team members and with patients and their relatives. All actions will be completed by November 10 in line with the coroner’s recommendations.

“Although these actions may not have changed the outcome for Neil, we are deeply saddened by his death, and our thoughts remain with everyone who was affected by this tragedy.”