Concerns have been raised that “repeating patterns” were not seen after a 33-year-old man was found dead at his flat just eight weeks after he was discharged from a mental health unit.
An inquest into his death heard that Brian Mountford, who was originally from Wakefield in Yorkshire but had later lived in Pwllheli in north Wales, was detained under the Mental Health Act on six different occasions.
He was initially diagnosed with schizoaffective disorder in 2017. His final admission into hospital was in November 2019.
He was released from the acute assessment ward at Salford Royal Hospital on December 6 last year only to return on a voluntary basis two days later. However he was told that a bed was not available to him.
His body was found at his flat in Kings Road, Irlam, Salford, less than two months later, on February 5, 2020.
Mr Mountford’s sister, Annelise Wilde, spoke at the inquest into his death, held at Bolton Coroners’ Court and said her brother was an aspiring barrister who had studied law at both at Bangor University and later in Manchester.
According to the Manchester Evening News he failed to complete his university course and suffered personal tragedies, which resulted in a deterioration of his mental health.
“I believe that when he lost his dad he still had a very good idea of where he wanted to be in life and still wanted a future and to make him proud,” said Ms Wilde, who revealed that she lost contact with her brother in 2017 after he had made deaths threats towards her.
“Growing up, he was very smart, very intelligent, very outgoing. Last time I saw him, he was a totally different person, I didn’t recognise him.”
Consultant psychiatrist Dr Jason Ip observed Mr Mountford after he was detained under section two of the Mental Health Act for the final time in November 2019.
Dr Ip told the inquest that Mr Mountford had called himself “the son of God” and claimed that his cannabis had been spiked with poison but claimed to be “immune to poison”.
After Mr Mountford had been detained at the hospital for 28 days it was decided that he become a ‘voluntary patient’ instead and he was released on December 6. He was asked to return on December 9 but instead turned up a day earlier asking to stay the night, the inquest heard. It was at this point he was told by Dr Ip that there were no beds available.
Ms Wilde told the inquest the same day her brother had posted a message on social media as a “cry for help”. The message read: “I love you all. I will never forget you.”
He failed to show up on December 9 and he was formally discharged on December 12.
Anne Speakman, a nurse at the Cromwell House community mental health centre, told the inquest that she had concerns about the way the case was handled because Mr Mountford had a habit of not taking his medication when he was outside of a hospital setting. She added that he had, while in hospital, made weapons out of utensils found on the ward and tried to choke a doctor.
The nurse said she visited Mr Mountford’s flat on several occasions after he was discharged but never got a response, even leaving notes through his door, sending text messages, and trying to contact him through his brother.
She raised a concern with local police on December 17, 2019, but told the hearing she did not know the result of that particular welfare check.
She visited again on December 24 last year and discovered that a light that had previously been on was turned off, leading her to believe that Mr Mountford was still alive at this point.
However when she visited his flat for the final time, on February 5 this year, she noticed flies inside and called the police. Officers then forced entry into the flat and discovered Mr Mountford’s body.
Pathologist Dr Sangeeta Verma told the court the medical cause of Mr Mountford’s death could not be ascertained due to the level of decomposition but added that two drugs were found in his system – both anti-psychotic medication.
Following his death the principal clinical psychologist at Woodlands Hospital, Dr Ruth Watson, was appointed as lead investigator on behalf of Greater Manchester Mental Health NHS Foundation Trust.
In a report into Mr Mountford’s treatment Dr Watson highlighted a number of “opportunities for learning”.
“It was really clear when reading Brian’s history that he had a sad pattern of these repeat admissions to hospital,” she said.
“He was admitted in a very unwell state; then recovered with use of medication; then there were long periods of not engaging him.
“He had a repeating pattern of admission and it was clear when he was in the community that it was very difficult to engage him.
“Looking at that history and liaising more with the community team might have helped us take a slightly different approach and that might have ended up in a section three and a CTO (Community Treatment Order). If we’d perhaps had a longer time to work with Brian perhaps we could have found out more about what would have helped in the community.”
Recording an open conclusion assistant coroner for Manchester West Stephen Teasdale said: “Brian James Mountford had a history of repeated admissions and subsequent non-engagement.
“As an inpatient he responded well however upon being discharged he would rarely engage with the community mental health team.
“There are no signs of illicit drug use other than cannabis. There is no evidence of underlying health complaints. He did have an irrational belief that he was immune to poison.
“There is no evidence of any intention to harm himself and there are no instances of self-harm or suicidal thoughts.”
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Following the inquest Mr Mountford’s sister said: “He was a very intelligent and outgoing person and he had very good outlook on life and where he wanted to be but obviously due to circumstances of what he’d been through, he changed.
“Our thoughts go out to everyone who was involved with Brian and was part of his life.”
Mr Mountford’s stepfather Cameron Wilde added: “He was articulate and very caring.
“Hopefully this will bring everything to a head so some good can come of it. Hopefully the report will stop other families going through this.”