A 48-year-old man who was struggling with the breakdown of his marriage and lost his job and his home all in a short period took his own life two days after discharging himself from hospital.

An inquest at Accrington Town Hall heard how Richard Waite had admitted himself to hospital for help on December 28, as he knew he was struggling with alcohol problems, depression and anxiety, but had discharged himself after being told to wait until he sobered up before a mental health referral could be made.

On December 29, his mother, Linda, raised concerns with the mental health team as she was worried about her son’s state of mind.

The inquest was told that Linda had been given some advice by the team over the phone but had been unable to refer Richard for immediate help as he had been asleep when the call was made.

Tragically, the following morning, his father went to check on him and found his son had hanged himself in his room.

Coroner Richard Taylor said a number of concerns had been raised by his parents after his mother spent all day on December 29 trying to speak with the crisis team, and was told the only course of action she could take to protect her son would be to take him back to A&E.

In fact, as his next of kin, she could have asked for her son to be sectioned under the mental health act for his own safety – something she was unaware of until after his death.

An investigation into the care and advice provided to Richard in the days leading up to his death was carried out by safety lead for mental health services in Lancashire, Ieuan Thomas-Cole, who said a number of lessons had been learned by the health trust.

Linda Waite told the inquest: “I feel let down. If someone gives you a crisis number then you expect someone to help.

“It took three or four phone calls before I even got through to someone. I started at 10am but it was 4pm before I got to speak with anyone.

“I knew he was at the end but I needed some immediate help. I just feel let down by that. You expect to be answered immediately by the crisis line and this didn’t happen.”

Mr Taylor said: “An awful lot of things went wrong in a short period of time - his divorce, the loss of a close friend, the loss of his job and the loss of his home, and it’s around this time that his drinking gets out of hand, and he talks about drinking to self medicate.”

The inquest was told how Richard had referred himself to mental health services in October and told them he had attempted to take his own life. He also told them he had referred himself to alcohol and drug service Inspire and was due to see them for help with his alcohol problems on October 28.

Because of this, the mental health team suggested a follow-up appointment be made in November to give him time to work with the team at Inspire.

During that follow-up, which was held over the phone due to the pandemic, Richard told a practitioner he tried to take his own life two years ago, but did not mention that he had ended up accessing mental health services in Barnsley, which operates under a different trust.

Mr Thomas-Cole told the inquest: “Information is not routinely shared between trusts so we did not know he had accessed mental health services in the past and the practitioner did not ask him this on the phone.

“He said at that time he had just completed a detox from alcohol and he had no plans to take his own life and therefore was deemed a low risk of suicide, but we would’ve liked to have seen a little more input from the practitioner.”

Mr Taylor asked Mr Thomas-Cole whether the red flags, such as the previous attempt on his life and his vulnerability having just completed a detox would not have warranted placing Richard in a higher risk category.

Mr Thomas-Cole said: “There should’ve been another follow-up from the mental health team and the practitioner has recognised that this could’ve been done and has learned from that.”

The inquest then heard how six weeks later in December, Richard presented at A&E after having taken an overdose of anti-depressants, but discharged himself before the mental health team had chance to assess him, and therefore no record was passed to mental health services about his overdose.

Then on December 29, his mother tried to access help, but was not provided with adequate information.

He was found dead at his parents' Old Hall Drive home in Accrington on December 30.

Mr Taylor said: “Is it predictable that he would’ve taken his own life? Well, all the red flags are there. Would it have been preventable? Possibly not.”

After Mr Taylor returned a conclusion of suicide, Mrs Waite said: “Richard was a dearly loved son and we want to thank the team at Inspire as they were very supportive and after he died, they showed great care and compassion to us.”