MENTAL health bosses have vowed to "learn lessons" following the death of a teenager who hanged himself after repeatedly telling medics that he was going to kill himself.
Jamie Nolan was just 19 when he took his own life at the Stonham’s House Men’s hostel in Chorley Old Road on April 12.
An inquest into his death heard the former Harper Green School pupil, who had an unsettled adolescence and was homeless aged 17, had repeatedly gone to the Royal Bolton Hospital and claimed he was going to commit suicide.
His mother, Elizabeth Nolan, begged for him to be admitted, but it was decided he was of a low risk of harming himself and could be better treated in the community.
Bolton Coroner’s Court heard that heard Mr Nolan was then discharged from the care of Greater Manchester West Mental Health Trust’s crisis team on February 21 — just a day after a noose was found in the room where he was staying.
Care workers believed he had planned for the noose to be found during a room inspection and maintained that psychological therapy in the community would be the best option.
Mr Nolan was then referred to primary care psychology services — but was deemed unsuitable for this care, and at the time of his death the 19-year-old was left in limbo with just a GP responsible for his treatment.
Greater Manchester West has since carried out an internal investigation into Mr Nolan’s death and a number of changes into the way services are run have been introduced.
Director of operations and nursing at Greater Manchester West, Gill Green, said: “Since the death of Jamie Nolan we have undertaken a detailed and thorough internal investigation as to the circumstances leading up to his death.
Jamie’s parents were able to contribute to the investigation and raise any questions they had about our services and our response to Jamie.
“We have also shared the actions we are taking to ensure that we do learn lessons and continue to develop and improve our services.”
One change, introduced since Mr Nolan’s deaths, means that referrals from the crisis team to other services can occur before a patient is discharged, meaning that there is no gap between services and no period of limbo for patients.
Speaking at the inquest, Christine Parker, assistant director for community services for Bolton Mental Health, said: “This will mean that patients are not left for a period without intervention.
“People can be referred to primary care services but if they are not deemed acceptable, there will now be a meeting to discuss what happens next.”
Mr Nolan’s step-father, Vincent Ashton said he felt this was “an obvious problem”.
He added: “Why didn’t staff point out that patients could be left in limbo if they were discharged and then not taken into primary care?”
The investigation also stated that the previous method of formulating risk assessments for patients “did not assist staff in understanding Jamie’s risk.”
Ms Parker confirmed that further training in this area has since taken place and that a new risk assessment system has been implemented.
Earlier in the inquest, assistant deputy coroner Geoffrey Saul was told how Mr Nolan had become obsessed with his health after his father was diagnosed with, and subsequently died from, the degenerative brain condition Huntingdon’s disease.
Recording a narrative verdict, Mr Saul said that “sub-optimal procedures for risk assessment and communication issues may have combined to make it harder to assess fully the risk of suicide for Jamie”.
He added that he was “satisfied” that Mr Nolan had intended to end his life on April 12.
The inquest comes after Greater Manchester West announced plans to remove 50 beds from the Royal Bolton Hospital in October in a bid to save £2.1 million.
Speaking after the inquest, Mr Nolan’s mother, Mrs Nolan said: “It was a fair judgement and I don’t think there was any other conclusion that could be reached.
“We will now consider what to do next.”