A CORONER has concluded there were ‘missed opportunities’ in the lead-up to a man’s death.
Kirsty Gomersal was speaking at the end of an inquest into the death of 28-year-old Joseph O’Doherty.
He grew up at Backbarrow, attending Leven Valley Primary School in the village.
Ms Gomersal accepted Mr O’Doherty died by hanging and there were no suspicious circumstances after he was found by a member of the public in Little Aynam, Kendal, on August 25, 2020.
Ms Gomersal also accepted the toxicology report that stated Class B drug cannabis had been found in Mr O’Doherty’s body before his death.
The inquest had heard that Mr O’Doherty suffered with his mental health prior to his death and had been diagnosed with emotionally unstable personality disorder (EUPD).
As a result of this, Mr O’Doherty had been referred to the Lancashire and South Cumbria NHS Foundation Trust (LSCFT) where he began to receive support.
However, Ms Gomersal has now pointed to missed opportunities, criticised the trust’s risk assessment procedure and highlighted a worker had failed to make their own notes when assessing Mr O’Doherty.
Ms Gomersal found Mr O’Doherty’s risk assessment had not been updated after June 9, despite a deterioration in his mental health afterwards. The inquest heard that on June 23, Mr O’Doherty had self-harmed and he was displaying a form of a low mood.
The coroner also stated that the trust had an ‘incomplete picture’ of Mr O’Doherty’s mental health.
A spokesman for LSCFT told the inquest the organisation had taken a number of steps following Mr O’Doherty’s death to help prevent future tragedy, including improved risk assessment procedures.
Ms Gomersal also noted that Mr O’Doherty had been prescribed medication for his personality disorder but had stopped taking it sometime between June and July 2020.
Mr O’Doherty had also missed appointments with his care co-ordinator, the inquest heard.
The LSCFT spokesman said he would have liked to have seen ‘somebody escalating’ Mr O’Doherty’s missed appointments and ‘raising concerns’.
He believed that conversations should have taken place with Mr O’Doherty’s family and that a medical review as well as a multi-disciplinary team discussion should have taken place.
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