A CORONER spoke of 'two major missed opportunities' at an inquest into the death of a Carlisle man who had struggled with mental illness for many years.

Peter McWeeny, 74, died at his Ellesmere Way home on July 23, 2021.

An inquest was held into his death in Cockermouth on Tuesday. Coroner Margaret Taylor heard that Mr McWeeny had previously worked as a painter and decorator.

He had three children and married his wife, Marlene, in 2003.

"We were a very close family," said Mrs McWeeny.

The couple had enjoyed a meal together the evening before he died.

"He later said he felt unwell so I gave him some paracetamol and told him to get some sleep."

When she checked on him the following day he was unresponsive. Emergency services were called and he was declared deceased.

The inquest heard that Mr McWeeny was diagnosed with paranoid schizophrenia in 1968. In 2004 he was diagnosed with psychosis. He later went on to be diagnosed with hypermania and, in 2020, with bipolar effective disorder.

The latter was diagnosed by Dr Judith Whiteley, associate specialist psychiatrist with the community team.

Mr McWeeny had been referred to Dr Whiteley by his GP and was due to see her in January 2020 but did not attend. She eventually spoke to him on April 27.

Ms Taylor questioned why this had not been relayed back to his GP.

The inquest heard evidence from Katie Rippon, an adult social care service manager with Cumbria County Council.

It also heard that the Home Treatment Team, part of Cumbria, Northumberland, Tyne & Wear NHS Foundation Trust, had worked with the family.

Mr and Mrs McWeeny had "very intensive support from the team", said Ms Taylor.

"At time of discharge he was assessed as high risk of self neglect and medium risk of vulnerability," she said, noting that his wife was caring for him - although she also had health issues.

The Home Team believed he would be allocated a care co-ordinator, said Ms Taylor. "This was also requested by Dr Whiteley. For reasons unclear no care co-ordinator was appointed," she said.

A post mortem noted significant quantities of paracetamol and other medication including tramadol and sulpiride, which could cause sedation, respiratory depression and cardiac arrhythmia. Medical cause of death was given as drug intoxication.

Ms Taylor concluded his death was as a result of 'misadventure'.

"He has deliberately taken the medication but did not intend it to end his life," she said.

"Peter had suffered from mental illness for many years and was prescribed medication, but he also took medication prescribed for his wife as well."

She noted he had various consultations with Dr Whiteley "Most were with Peter's wife or other family members as he did not feel well enough to talk over the phone," said Ms Taylor.

The inquest heard that when social care was first offered, it was declined by the family.

It also heard that on July 13, 2021, police raised concerns about a vulnerable adult but this referral was not received by social care until July 26, after Mr McWeeny's death. It was acted upon by the team immediately.

"The reason for delay is not clear but it concerns me. It reflects a missed opportunity," said Ms Taylor.

In her summing up, Ms Taylor said: "I have mentioned two major missed opportunities but even if they had not been missed I do not find Peter's death would have been avoided."

Regarding the mental health trust, she said: "I'm surprised there were no investigations. The absence of a care co-ordinator is a very real concern.

"It's clear Dr Whiteley wanted one and the Home Team anticipated one.

"They could have played a valuable role in the quality of Peter and his wife's life and engaged with other services if necessary."

She also raised concerns about the Did Not Attend policy - following the GP not being told Mr McWeeny had not attended his initial appointment.

"I need some reassurance that this policy exists," she said.

"I think there's issues about working together as agencies and sharing of information, so everyone works together as a team to better help an individual.

"Within 28 days I would like a letter addressing those concerns so I can be reassured they have been noted by the trust and action taken.

"I would have expected the issue of the care co-ordinator to be taken up by the trust."

In relation to adult social care, Ms Taylor said: "I appreciate when a client declines involvement that puts them in a difficult position.

"I wonder what capacity was assessed or any explanations about alternative care, given the evidence that the daughter liaised with the social worker about their discontent with the care package."

She also raised concerns about the delay in logging safeguarding issues.

"I need reassurance someone has explored this," said Ms Taylor, who agreed that the county council should liaise with police on this matter. 

"I would like a letter from the local authority within 28 days. Providing I'm happy, my regulation 28 duties will not be triggered."

"Peter's case shouts out for multi-agency working. I do not believe they were working together to provide the support for Peter and his wife, who were vulnerable," said Ms Taylor.

She offered her condolences to his family.

"I have been given a snapshot of Peter. He obviously had a generosity," said Ms Taylor.

"He had a very loving wife and they obviously had a very strong relationship. She was clearly devoted to him."

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