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Man took his own life weeks after nurse decided he was not an 'urgent priority'


A man took his own life just weeks after a mental health nurse decided he was not an urgent priority, an inquest heard.

A GP had referred Stephen Startup, 28, after he told of having suicidal thoughts, but the nurse who did his assessment said it wasn't likely he would act on it.
The inquest heard the nurse hadn't done any assessment training since 2015 and had been working in a small team.

Police found Mr Startup's body in his flat in Manchester on November 19 2019 after his worried ex-girlfriend called 999 from London.

He had been diagnosed with bipolar disorder and was reported to have struggled with his mental health in the past.

His brother, Kieran, told the hearing that Mr Startup's highs were "extremely high" that he said he enjoyed manic episodes because they made him "more creative" and happy, but he admitted the "lows" and depression that followed were not worth it.

The inquest heard that Mr Startup used inheritance money from his mother to go travelling in Canada in February 2019, but was involved in a car crash, which he later told his ex-girlfriend was a suicide attempt.

He had made other attempts to die by suicide, and visited his GP in September 2019.

He told a nurse he was depressed, and mentioned thoughts of self-harm, the inquest heard.

The next day, Mr Startup saw his doctor and was given an urgent referral to a mental health team, who were told he was "socially isolated" and depressed.

The nurse who looked at the GP referral, Kevin Kennedy, downgraded it from urgent to routine, the hearing was told.

If his case had been judged to be urgent, Mr Startup would have been seen by a mental health team within one and five days while a routine patient must be seen within 21 days.

The doctor had put Mr Startup down as an urgent priority, as he was a "current risk" of accidental or deliberate, self-harm and suicide.

Mr Kennedy, explaining why Mr Startup was downgraded to routine, said there was no sign of alcohol abuse, which would usually act as "Dutch courage" for somebody to act on their self-harm thoughts.

The nurse visited Mr Startup at his flat for about 45 minutes on October 7, 2019, noting the patient seemed "intelligent, articulate, well groomed" and had no signs of "alcohol abuse, jaundice or tremors.”

Mr Startup was referred to a psychiatrist to talk about going onto medications and an appointment was booked for the following January.

A serious incident review was launched by North Manchester's Mental Health Team.

Giving evidence about her role in this, Leanne Hopwood, said guidelines for nurses do not give a timeframe on how long a patient should wait for an appointment.

She said that guidelines do not suggest outcomes, such as downgrading a patient's urgent status, need to be discussed with managers, she added.

The coroner said: "Mr Kennedy was left to his own devices and best judgment on limited information."

Ms Hopwood agreed, saying Mr Kennedy last had assessment training in 2015 and nurses must have it every three years.

Following the investigation, the trust was given recommendations that have been dealt with, the inquest heard.

The coroner, who ruled that Mr Startup had died by suicide, said: "It seems there was a significant delay in getting Stephen to see a psychiatrist. It is difficult to see why there was such a delay. I am in no part apportioning blame; it is just a striking feature in this evidence. Whether or not it would have made any difference, I don't know."

After the hearing, Mr Startup's brother Kieran said: "There was obviously some missed opportunities. He was a really lovely guy. He really deserved a better hand in life than what he got."

Director of nursing and governance for Greater Manchester Mental Health NHS Foundation Trust, Gill Green, said: “We offer our sincere condolences to Mr Startup’s family and friends.

“We understand the concerns about the referral process, but after looking closely at the circumstances of this case, we are confident the correct decision was made at the time, and Mr Startup was seen in a timely manner.

“We are very sorry Mr Startup’s condition deteriorated following his appointments and our thoughts are with those who cared for him.”