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A Wirral dad who was found dead at his home took his own life after attempts to carry out a mental health assessment were unsuccessful, an inquest has found.
Thomas Browning's body was discovered at his home in New Ferry on the night of November 28 last year, as reported by the Wirral Globe.
A recent inquest at Gerard Majella Courthouse in Liverpool heard the 41-year-old died by hanging.
Nicholas Smith, a team manager for the Community Mental Health Team on the Wirral had a warrant to conduct a mental health assessment at Mr Browning's home on the same day. He went to the property with police officers and tried twice to contact Mr Browning.
Mr Smith knocked on the front door and shouted Mr Browning's name through the letterbox, while police officers checked around the back of the property.
The property seemed empty, but a dog was heard barking inside, and the television was heard.
Mr smith left the property, thinking that Mr Browning wasn't home, but at the inquest it was noted it was probable he was at home.
A colleague had also attempted to contact him the previous day before suggesting that a warrant should be obtained.
Later that evening, concerns were raised by Mr Browning's family and his former partner Vicky after he failed to make his usual nightly phone call to their children.
His body was later found at the property by a member of Wirral Council's Emergency Duty Team (EDT), an out-of-hours social work management team.
The team executed the warrant with police after Vicky raised further concerns.
Mr Smith said: "My intention when applying for a warrant was to help assess him. There was some evidence that, potentially, he was out. The decision not to execute the warrant was wrong, because Tom was in the house. I know that now.
"We'd missed an opportunity to provide the necessary care and treatment".
The inquest heard Mr Browning had declining mental health, suffering with paranoid and delusional thoughts including a belief that he was being persecuted by the Irish Mafia and that professional services were trying to harm him.
He was referred for help earlier in the year but was reluctant to accept help. He also had a history of self-harm.
Mr Browning had recently travelled to Europe without telling others and returned home three weeks before his death. His contact with his children had ended around a month earlier.
It also emerged that he had recently been looking for ways to end his life.
Coroner Helen Rimmer was critical of the handling of the case, highlighting insufficient record keeping and a "lack of consistency" in sharing relevant information.
She said: "The shortcomings contributed to a delay in the mental health assessment. Had the warrant been executed earlier, the outcome could have been different.
A dedicated Approved Mental Health Professional (AMHP) Hub is now operated directly by Cheshire and Wirral Partnership NHS Foundation Trust to ensure handover notes and information about individual cases are shared correctly.
An AMHP checklist monitoring form has also been introduced to reduce the risk of information being lost between services, with further training planned on its use.
Recording a narrative verdict, Ms Rimmer said: "Tom died from a deliberate act following deteriorating mental health characterised by paranoid and delusional thoughts.
Kimberley Peet, Senior Associate in the Clinical Negligence team at JMW, said Tom's family had been devastated by his death and the findings of the inquest.
She said: "Tom was an adored son, friend and father and his sudden death last year has devastated his family: the past year has been extremely difficult for all of those who loved Tom.
"It is even more difficult for them to learn that there were missed opportunities and shortcomings in the care he received."
Tom's ex-partner and the mother of his children, Vicky Sheridan called Tom's loss an "incredibly difficult time". She added she was "heartbroken" over the failings of the local mental health services.
Ms. Sheridan also said if the warrant had been executed as planned, "Tom would have been home."
A joint statement from Wirral Council and Cheshire and Wirral Partnership NHS Foundation Trust offered condolences to Browning's family and highlighted improvements made in recent mental health support. Improvements introduced include "enhanced risk assessment and escalation processes and strengthened information-sharing arrangements to support continuity of care."
