A man killed himself weeks after he was downgraded from an 'urgent' priority by the mental health team.
Stephen Startup's GP had referred him for desperate help after a chat about his suicidal thoughts but the nurse who did this assessment said it wasn't likely he would act on it.
After the 28-year-old took his own life, it was revealed at an inquest yesterday that an investigation by North Manchester's Mental Health Team heard the nurse hadn't done any assessment training since 2015 and had been working in a small team.
Mr Startup, who loved to explore and go on adventures, was found dead at his Manchester flat by police officers after his worried ex-girlfriend called 999 from London.
Manchester Coroners' Court heard today that he had been diagnosed with Bi-Polar and had struggled with his mental health in the past.
Giving evidence, his brother Kieran said his highs were 'extremely high' - so much so he said he enjoyed the manic episodes because he was 'more creative' and happy but later admitted the 'lows' and depression that followed were not worth it.
When their mum passed away he had used inheritance to 'take his chances' and make a fresh start by buying a flat in Manchester city centre.
He also used the money to go travelling Canada in February 2019 but on the other side of the world had a car crash - later revealed as a suicide attempt to his ex-girlfriend, who he was 'very honest with', the court heard.
Other attempts to take his own life were noted by the coroner who heard that Mr Startup had visited his GP on September 24, 2019.
There he told a nurse he was depressed and mentioned thoughts of self-harm.
His doctor saw him the next day and made an urgent referral to the mental health team saying he was 'socially isolated' and depressed.
Kevin Kennedy was the nurse who looked at the referral from the GP and decided to downgrade it from 'urgent' to 'routine'.
An urgent referral must be seen by the mental health team within one to five days. A routine patient needs to be seen within 21 days.
Dr Clothes had marked Mr Startup as an urgent case, writing in the form - which was read out to the court that he was a 'current risk' of accidental or deliberate self-harm and suicide.
Justifying his reasons, Mr Kennedy said there was no sign of 'alcohol abuse' which would usually act as 'dutch courage' for somebody to act on their self-harm thoughts.
He booked in a visit to see Mr Startup at his flat on October 7, which lasted around 45 minutes.
There he referred him to a physiatrist to talk about going onto medications.
He said he seemed 'intelligent, articulate, well groomed' with no signs of 'alcohol abuse, jaundice or tremors'.
That appointment was booked for January 14.
However, on November 19, Mr Startup was found dead at his flat.
The trust launched a 'serious incident review' about what had happened and Leanne Hopwood appeared at court to give evidence about her part in the investigation.
She described how guidelines from the trust for the nurses does not give a timeframe on how long a patient should wait for an appointment and does not suggest that outcomes, like downgrading a patient's urgent status, need to be discussed with managers.
Coroner Anthony Mazzag said: "Mr Kennedy was left to his own devices and best judgement on the limited information."
She agreed, also revealing how Mr Kennedy last had assessment training in 2015 and nurses must have it every three years.
At the end of the investigation, the trust was given recommendations that have been dealt with.
The coroner ruled that Mr Startup had died by suicide, and said: "It seems there was a significant delay in getting Stephen to see a physiatrist. It is difficult to see why there was such a delay. [I am in] no part apportioning blame it is just a striking feature in this evidence.
"Whether or not it would have made any difference, I don't know."
Speaking to the Manchester Evening News, his brother Kieran Startup said: "There was obviously some missed opportunities."
He said if they had been taken, he might still be here or he might not be, adding: "We will just never know now.
"He was a really lovely guy. He really deserved a better hand in life than what he got."
Gill Green, Director of Nursing and Governance for Greater Manchester Mental Health NHS Foundation Trust said: “We offer our sincere condolences to Mr Startup’s family and friends.
“We understand the concerns about the referral process, but after looking closely at the circumstances of this case, we are confident the correct decision was made at the time, and Mr Startup was seen in a timely manner.
“We are very sorry Mr Startup’s condition deteriorated following his appointments and our thoughts are with those who cared for him.”
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