THE family of a 38-year-old man who was found hanged at home said they feel like the NHS 'failed him' after an urgent referral to the mental health team had not been carried out appropriately.

Robert Whelan was found hanging at the house he was staying at in Jacob Street in Accrington on February 26.

An inquest at Accrington Town Hall heard that on February 3, Robert had been rushed to Royal Blackburn Hospital after attempting to take his own life.

Coroner Richard Taylor told the inquest that so severe were his injuries he had to be transferred to Royal Preston Hospital to undergo plastic surgery.

Mr Taylor said: "Before he could be seen by the mental health liaison team at Blackburn he was sent to Preston.

"His sister, Stephanie, was told he was going to be seen by the mental health team before going to Preston but he wasn't. Nor was he seen when he got to Preston."

The inquest was told that a verbal message had been given to paramedics who were to inform staff at Royal Preston that Robert needed a mental health assessment due to his attempted suicide.

However, the 38-year-old, who had struggled with alcohol and substance misuse and had received help on and off for a number of years, was allowed to leave the hospital before this could happen.

Lancashire Telegraph: Robert WhelanRobert Whelan

Robert's family raised concerns a number of times in the following two weeks, with the crisis team and his GP, and on February 16 his doctor, Fiona Ford, had a phone conversation with him which prompted her to urgently flag him up to the mental health team.

Giving evidence at the inquest she said: "He admitted to me that he had really wanted to end his life when he cut himself at the beginning of the month.

"I also made a note that he was unusually upbeat and that this didn't match his character. I wrote a very urgent referral highlighting the fact that I thought he was still a high risk of suicide."

Attempts were made to contact Robert on February 17, 18 and 19, but nurses from the mental health team were unable to get in touch with him.

The inquest heard that a letter was sent to his home advising him that should he not make contact with them to arrange appointment they would consider he no longer needed the service.

No attempt was made to visit his home address or contact any family member to discuss his mental health and his referral was then down-classed from urgent to routine.

The last contact he had with any of his family was around February 21.

He was found dead on February 26.

Mr Taylor said: "Just because someone hasn't been able to be contacted doesn't mean they should stop trying to contact them. Had more enquiries been made either via his GP or his family then information on how to contact him could've been obtained from those sources. There were missed opportunities here."

Suzanne Currey, an occupational therapist from Lancashire and South Cumbria NHS Foundation Trust was asked to carry out an investigation into the procedures and said recommendations had been made.

She said: "Nothing followed him from Blackburn to Preston except a verbal message to the paramedic.

"There was a recommendation following my report that standard operating procedures are followed and there's a clear escalation process for when an urgent referral has been made. Reassurance has been made that this is happening."

Speaking after the inquest, Robert's brother, Ian Whelan, said they had tried to get their brother sectioned at the beginning of February after his first suicide attempt, but had been told this was not an option until he had been assessed by the mental health liaison team - which didn't ever happen.

He said: "I feel like we looked for help but we didn't receive it.

"He should never have been released from hospital at the beginning of February without being assessed - he wasn't in the right frame of mind.

"He wasn't protected. I feel like the NHS failed him - they had a duty of care and they didn't uphold that."

Mr Taylor recorded a conclusion of suicide and said Robert was found dead on February 26 after an urgent referral to mental health services had not been appropriately carried out.

If you have been affected by any of the information within this article, or you are experiencing feelings of anxiety or depression you can contact the Samaritans free on 116 123.