A CORONER has called for “urgent action” from the region’s, Prestwich-based mental health trust to review the way its staff are trained following the tragic suicide of a builder.

Daniel Moran, aged 32, was found hanged at his home in Bentley Court, Farnworth, on July 14, 2019, after self-discharging from hospital, contrary to medical advice.

An inquest in January 2020 heard that Mr Moran had a complex medical history, including depression and alcohol misuse, and had attempted to end his own life on multiple occasions in the period leading up to his death.

He was hospitalised following a suicide attempt on July 11, 2019, and was admitted the following day as a voluntary patient.

However, during this period Mr Moran was said to have become aggressive and agitated, and requested self-discharge.

As he did not meet the criteria to be detained under the Mental Health Act the 32-year-old was then allowed to self-discharge.

In a report to prevent future deaths from occurring ­— sent to the chief executive of the Greater Manchester Mental Health NHS Foundation Trust ­— HM assistant coroner for Manchester West, Rachel Syed, raised concerns about staff training on four identified issues.

Ms Syed ‘s report stated: “During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless actions is taken.”

The first of these matters concerned staff being unaware of situations where it was “appropriate to breach patient confidentiality and notify family or friends, when concerns arose regarding patient safety/welfare”.

Ward staff also need to have “greater understanding of how how to prioritise new admissions and ensure the better flow of patients through the ward”, the report said.

Thirdly, “ward staff and doctors need to have greater understanding of each other’s roles and responsibilities in relation to managing patient risk and whose responsibility it is to authorise leave and ensuring contemporaneous documentation are kept in relation to the decision making rationale” ­— this includes documenting changes in risk and capacity.

Finally, “doctors and ward staff involved in making decisions about self-discharge should consider the circumstances of admission as well as current risks when making decisions around discharge.

“They also need a greater understanding of the circumstances when it is appropriate to seek more senior opinions in regards to whether the patients meets the criteria to be detained under the Mental Health Act.”

This should again also include ensuring contemporaneous documentation is kept in relation to decision making rationale, the report added.

If you have been affected by this story and would like to talk to someone then call Samaritans for free from any phone on 116123.

Alternatively Papyrus, dedicated to helping people under 35 at risk of suicide, via its HopelineUK service.

Visit papyrus-uk.org/hopelineuk/ or call 0800 068 4141, text 07786209697 or email pat@papyrus-uk.org