A MAN who killed himself just hours after discharging himself from a mental health unit should never have been allowed to leave according to his family.

Daniel Moran, 32, was found hanging at his flat at Bentley Court in Farnworth on July 14 last year after spending the previous day as a voluntary inpatient in Beech Ward at Royal Bolton Hospital.

The previous day, Mr Moran, who had a long history of mental illness and had made repeated attempts on his own life, had been admitted to A&E after being found by a friend with a noose around his neck.

But despite then taking an overdose of anti-depressants in the ward’s waiting room, Mr Moran was allowed to discharge himself having been deemed well enough to leave following an assessment by a junior doctor.

An inquest held in Bolton before coroner Rachel Syed heard how Mr Moran had drunk turps and bleach in the months preceding his death and also bought a length of rope with which to hang himself.

Described as a “binge drinker”, Mr Moran, who worked as a builder, had visited his GP three times during June in an attempt to deal with his depression.

The inquest heard Mr Moran was brought to A&E by police officers and was triaged at 6.17pm on July 11, however due to being intoxicated he had to wait three hours for an assessment.

Mental health practitioner Jacqueline Tombs told the inquest she saw Mr Moran in the early hours of July 12 when he told her he “didn’t feel safe going home” and felt he was “being fobbed off” by hospital staff.

It was arranged for Mr Moran to be admitted to Beech Ward where a bed was available but deputy ward manager Emma Crompton told the inquest the bed was not in fact ready due to another patient not vacating it yet.

Mr Moran had become increasingly frustrated and asked to leave to buy some tobacco, but it was thought he may have used the time off the ward to drink alcohol.

After returning at around 5.30pm he was heard being “hostile and threatening” to staff, accusing someone of entering his room and stealing his tobacco.

Ms Crompton said he began demanding to leave and was saying he didn’t feel safe on the ward and climb over the fence if he was not allowed to discharge himself.

“He was very angry towards staff and we could not placate him verbally,” she said. “He was fixated by his tobacco going missing.”

A junior doctor was called to assess Mr Moran,and he was allowed to discharge himself but he was later seen taking a number of pills outside the ward after which the police were called.

Later on in the evening, Mr Moran contacted the Beech Ward and asked to return but was told there was no longer a bed available.

He was later found dead by police officers after neighbours found a note pushed under his door.

A Serious Incident Review prepared by William Reekie was heavily criticised by Ms Syed who called it “very defensive”.

She said: “Daniel is not just a file of papers and I found it difficult to understand your evidence because there were a lot of presumptions and ifs and buts.”

Believing that “circumstances creating a risk of other deaths will occur, or will continue to exist in the future”, Ms Syed, returned a narrative verdict and ordered a Regulation 28 Report to be issued to Greater Manchester Mental Health NHS Foundation Trust adding that she found their lack of documentation “astounding”.

Ms Syed also criticised staff members' decision not to contact Mr Moran's family and friends and questioned why a more senior doctor was not involved in assessing the 32-year-old. 

Following the inquest, Gill Green, director of nursing and governance for Greater Manchester Mental Health NHS Foundation Trust said: “We express our deepest condolences to Mr Moran’s family and friends at this sad time.

“We fully accept the findings the Coroner has made.  In order to learn from this, we have looked carefully at the care and treatment we delivered, and we have put action plans in place to reduce the risk of this happening again.  We would like to offer assurances that these actions are our priorities and will be carefully monitored.

“However, Mr Moran and everyone who cared for him remain in our thoughts.”

Speaking afterwards, Mr Moran’s cousin, Collette Cornfield, said: “I don’t think mental health patients in general get the help or support they need.

“There was a lapse in Daniel’s care and I feel a lot of things could have been prevented, but there are just not enough resources to deal with people with mental health problems.

“He spent almost 12 hours waiting around for a bed and then it wasn’t ready. I work for the NHS and I know there is bed pressure but documentation is key and I could see that wasn’t happening.

“If Daniel knew how much we all loved and cared for him it might have saved him, but he was always a loner and a quiet lad. If you are a man and you feel alone and in that situation just talk to someone. It is OK to feel alone. Just speak out and get the help you need.”