Steven Myers, 49, from Wythenshawe, was found dead in room 222 at The Amblehurst Hotel in Sale on December 2 last year.
Previously homeless, he had been living in the ‘chaotic’ temporary hotel accommodation on Washway Road for eights months up until his death, the inquest heard.
An inquest into his death heard Mr Myers had been left ‘very upset’ when he learned from his GP, just a few days before he took his own life, that he had been discharged by the mental health team.
His GP referred him a second time but the inquest heard Greater Manchester’s mental health trust arranged an appointment for December 7, five days after his death.
Detectives who were called to Mr Myers’ death found no evidence of any third party involvement, police coroners officer Andrew Stevenson told the inquest in Stockport on Monday.
A post mortem examination revealed marks on his groin and lower legs suggesting he had injected himself with drugs while toxicological tests revealed evidence of heroin, codeine, cocaine and an anti-psychotic drug, quetiapine, in his body.
His GP, Fiona Greenslade, told the inquest she had a telephone consultation with Mr Myers on October 8 last year and saw from his medical notes he had a long history of mental health problems and drug use.
The witness said the patient reported his ‘psychosis’ was deteriorating, and that he was hearing ‘whispers outside his door’ although he went on that he would not take his own life because of how much he loved his grandchildren
The doctor referred Mr Myers to the mental health team.
Mr Myers spoke to a consultant psychiatrist on October 19 but he was discharged following a telephone consultation on November 23, the inquest heard.
Dr Greenslade said the decision left the patient ‘very upset’ as he felt he needed ‘psychological input’ and she agreed to ‘re-refer him’.
On December 2 the GP practice received a letter offering Mr Myers an appointment with mental health services. while the suggested appointment date was December 7, five days after his death.
Christopher Ranson, a senior social worker at Greater Manchester Mental Health NHS Foundation Trust, told the inquest it first received a referral for Mr Myers in June 2020 following an ‘episode’.
He underwent cognitive behaviour therapy years earlier which he found to be successful but he declined it on this occasion and he was discharged back into the care of his GP, Mr Ranson told the inquest.
Mr Ranson, giving evidence on behalf of a colleague who had carried out the assessment, agreed with the coroner that Mr Myers felt as if he had been ‘pushed from pillar to post’.
The witness also agreed the patient should have been referred on to the mental health primary care team.
Recording a verdict of suicide, coroner Chris Morris concluded Mr Myers had died of a ‘mixed drugs overdose having recently been discharged from mental health services’.
He also had a ‘long history of substance misuse’ and reported using illicit drugs to ‘to help him deal with some of the symptoms’.
He was staying at The Amblehurst Hotel in Sale which was ‘not an ideal situation for him’, said the coroner, who noted the accommodation had been described as ‘chaotic’.
“He regarded himself as as experiencing worsening psychosis that he associated with mental health problems during that time,” said Mr Morris.
It had been difficult for Mr Myers to distinguish between a psychotic episode and ‘noise from the living environment’, said the coroner.
Mr Myers was assessed but it had been concluded any treatment was unlikely to benefit him and he was referred back to his GP who then re-referred him, he said.
He went on that ‘tragically’ Mr Myers was found dead in his hotel room on December 2, leaving behind two notes which he said he regarded as notice of his intent to end his own life.
Following the hearing, Mr Myers’ mother Hazel said her son, who was known as Benny, had been ‘failed’. “He was passed from pillar to post,” she said.
Gill Green, Director of Nursing and Governance at Greater Manchester Mental Health NHS Foundation Trust (GMMH) said: “We offer our deepest condolences to Steven’s family, friends, and all those who cared for them at this sad time.
“Though the Coroner ruled that the care provided by the Trust did not contribute to Steven’s death, there are always things to be learned from tragic incidents such as this, and actions to be taken to ensure we provide the best possible care to our service users.
“Since the incident, following a comprehensive review into the care Steven received, we have delivered thorough staff training and education regarding the referral process into other services within GMMH, and best practice for clearly documenting patient information.
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