Young Wigan dad took his own life after family concerns missed

Danny Holt-Scapens’ family contacted North West Boroughs Healthcare NHS Foundation Trust when he was found with a rope, intending to take his own life, in July.

But the 23-year-old did not want to engage with services and his family was told to contact police if they had further concerns for his welfare.

The health trust worker made no note of the call and the organisation made no further contact with Danny, who was employed as a ground worker.

On October 10, Danny died after being found hanged in the garden at his home on Edward Drive in Ashton.

An inquest into his death, held at Bolton Coroner’s Court, heard Danny started using cannabis in his late teens and got into debt to fund his habit.

He was depressed and anxious and went to see a doctor, but he did not attend follow-up appointments or take medication.

His behaviour did improve after he spent two weeks in a rehabilitation facility in Manchester, but it was later “up and down”, the inquest heard.

On July 30, his stepfather Matthew Scapens found a rope with a noose in Danny’s bag.

He called North West Boroughs’ crisis management team and Danny spoke to them, but said he did not want to engage and wanted to make his own decisions.

Danny’s GP told the inquest he had been diagnosed with depression and struggled with anxiety.

In September he said counselling had not helped and reconsidered a previous suggestion of medication.

He had no plans to take his own life, though had mentioned having suicidal thoughts in earlier appointments and cited his family and friends as reasons to keep living.

But three weeks later, Danny, who had a young daughter, was found dead.

A post-mortem examination found the cause of death was hanging. Cannabis was found in his body at a recreational level.

GP Dr Prakash Lokanadem, from Ashton Health Centre, told the coroner: “I have gone over this again and again and I couldn’t have predicted it at all. There were no signs.”

Christopher Peake, investigation lead with North West Boroughs’ patient safety team, said there was no contact with Danny after July 30.

The trust was contacted after his death and found no record had been made of the call. An audit was carried out of the electronic care record system which showed his records had been accessed.

During the investigation, the practitioner who spoke to Danny and his family was interviewed but did not recall the conversation.

Mr Peake said the lack of evidence of the call fell below the standard expected of the trust.

He admitted there was a “missed opportunity to fully engage with Danny”.

More advice about a welfare check and a follow-up call could have been made and there was a lack of joined-up working between agencies, he said.

Mr Peake said: “We are working with Matt and his family to hear Danny’s voice and his story and there are plans to share that with a wider audience.”

Natalie Molyneux, matron for quality on the trust’s senior leadership team, agreed more could have been done.

She said an assessment should have taken place by phone, a follow-up telephone call made or the offer of a home visit.

When asked by the coroner whether the missed opportunity was individual or systemic, she said: “I would like to think it is an individual opportunity which has been missed and shouldn’t have been missed.”

She said the woman who spoke to Danny now has increased clinical supervision and an in-depth review is being carried out to identify any learning opportunities the trust can offer.

Danny’s mother Lesley Scapens said: “As a family we want no blame attributed to the poor nurse on the end of the phone. We completely understand the stretch, the pressure the assessment teams are under.”

The inquest also heard that in the week before his death, police were called to two domestic incidents involving Danny and his ex-partner as a result of child contact concerns. No crimes were recorded.

While there were no mental health concerns on October 2, when officers attended five days later, this was discussed. Danny did not provide consent for additional support and officers felt he had full capacity to make that decision.

His family asked why officers did not take action under the Mental Health Act, but the police coroner’s officer in court could not provide information about that. The coroner asked for more information to be obtained.

Coroner Rachel Syed recorded a conclusion of suicide.

She said: “I find that there was a significant missed opportunity for the mental health services to properly engage and treat Danny for his mental health problems.

“What I can’t say is that, on balance of probabilities, had that treatment been provided appropriately, that that would change the outcome. That would be a huge leap for anyone to make.”

She will issue a Prevention of Future Deaths report to the health trust focusing on the need for better inter-agency working and record keeping, and for documentation highlighting how clinicians deem someone to have capacity.

Telling Danny’s family there was nothing more they could have done to prevent his death, Ms Syed said: “It is a tragic waste of a 23-year-old man’s life and I truly hope that people who have mental health difficulties will engage with mental health services and try to prevent these kinds of deaths.”

A message from the Editorial Director, Gillian Parkinson: Thank you for reading this story on our website.

But I also have an urgent plea to make of you.

In order for us to continue to provide high quality local news on this free-to-read site and in print, please purchase a copy of our newspaper as well.

With the coronavirus lockdown having a major impact on our town centres and many of our valued advertisers - and consequently the advertising that we receive - we are more reliant than ever on you buying a copy when you pop out for your essential shop or subscribing for delivery.

Our journalists are highly trained by the National Council for the Training of Journalists (NCTJ) and our content is independently regulated by IPSO to some of the most rigorous standards anywhere in the world. Our content is universally trusted - as all independent research proves.

As Baroness Barran said in a House of Lords debate this week on the importance of journalists: "Not only are they a trusted source of facts, but they will have a role to play in rallying communities and getting the message across about how we can keep ourselves and our families safe, and protect our NHS. Undoubtedly, they have a critical role."

But being your eyes and ears comes at a price. So we need your support more than ever to buy our newspapers during this crisis. In return we will continue to forensically cover the local news - not only the impact of the virus but all the positive and uplifting news happening in these dark days.

We thank all our readers and advertisers for their understanding and support - and we wish YOU all the best in the coming weeks. Keep safe, and follow the Government advice. Thank you.

HOW TO SUBSCRIBE: You can subscribe for delivery by contacting us at [email protected] or calling us on 0330 4033004 for details of a participating newsagent near you.