Wigan dad was let down by health system

Bolton Coroners' Court
Bolton Coroners' Court
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A health trust is making changes after the wrong advice was given to a man days before he took his own life.


Steven Baker went to Claire House in Ince to ask to be sectioned as he believed he would kill himself if he left.

An inquest heard the 29-year-old was told to go to Wigan Infirmary’s A&E unit for help - but he could have been seen there instead.

He had already spent five hours at A&E that night and did not want to go back, Bolton Coroner’s Court heard.

He told assistant psychologist Emma Bruce and her supervisor he would be safe that night and went home.

Ms Bruce spoke to both Mr Baker and his mother the next day and they said he was not feeling too bad.

But the father-of-one was found hanged six days later, on March 27, in woodland off Belle Green Lane in Ince, near his home on Edinburgh Close.

Tim McPhee, head of service for living life well at North West Boroughs Healthcare NHS Foundation Trust, said Mr Baker should not have been told to go to the A&E unit.

He said: “That’s not the pathway. He shouldn’t have been told to go back to A&E. It’s the job of the team you are under to make the recommendation for what treatment should take place. ”

There were also concerns that although Mr Baker had previously been diagnosed with personality disorder, the pathway used to treat this had not been followed.

Mr McPhee said professionals decided to hold motivational interviews instead.

He explained changes were now being made within the trust, with staff being made aware of what should have happened, pathways being reviewed and plans for an external provider to give training on assessments to all staff.

The inquest heard Mr Baker had a happy childhood and worked as a window fitter.

But around two years ago, he admitted he had been using drugs for around 10 years.

He sought help to stop taking drugs, but his father Paul Baker told the inquest he started drinking instead.

He was seen by health services, but his mental health deteriorated last year.

He referred himself to Addaction in May last year to address his cocaine use.

Michael Brady, recovery co-ordinator, said Mr Baker made progress and attended a support group but suddenly stopped in December.

His family told the inquest his working hours had changed and he could not get to the group in time.

The motivational interviews were also arranged.

But the inquest heard he told his mother he wanted to kill himself on March 20, so she phoned the police and he was taken to A&E.

He went to Claire House the following day and it was then he asked to be sectioned.

Mr Baker was reported missing on March 25 and was found the next day, but he left the house again that evening after a row with his parents.

The next day his family heard a body had been found in woodland nearby and discovered it was Mr Baker.

He died by hanging and tests showed he had prescribed drugs and alcohol at around double the legal drink-drive limit in his body.

Recording a verdict of suicide, coroner John Pollard said: “He did have these mental health issues and he was seeking to address them and I think it is fair to say that the system let him down - the care system, not the individuals who have appeared here today but the system and the way that he ought to be protected.”

He said he had “some degree of confidence” that changes would take place.

Afterwards, Mr Baker’s family said improvements were needed and described him as having “a heart of gold”.