The family of a Workington man who took his own life feel he was ‘let down’ by mental health services, an inquest has heard.
But a coroner found that while there were problems with the way the NHS Trust recorded her care, this did not contribute to her death.
Aarran Tierney, 29, died on April 7 last year at his home on Milburn Street in Workington.
An inquest into his death was held at Cockermouth Coroner’s Court on Tuesday.
A statement was read on behalf of her sister, Tanya Tierney.
Tierney was born in Whitehaven in November 1991 and grew up in Salterbeck in Workington. He was the middle child with an older sister and a younger twin brother and sister.
He was “a happy boy growing up” and “angry at Manchester United”.
When he was 11 years old, he was running across the street in Salterbeck when he was hit by a pickup truck. This caused a brain hemorrhage and he had to be put into a coma. His sister said it took him a long time to recover.
He loved spending time with his friends and going to Uppies and Downies. He was always a fan of Uppie and went to all the games.
Tierney was a “mama’s boy” and “hit him hard” when his mother, Collette, died in 2015. He had suffered “for some time” with his mental health since her death.
The inquest was told Tierney first attempted suicide in January last year.
On February 24, 2021, he attempted suicide again. He called the police and told them that he intended to end his life.
He was detained under the Mental Health Act and was taken to A&E by police. His sister said he had been left alone in a hospital room.
Miss Tierney said: “I feel like he was let down and neglected by the mental health team.”
Tierney was found by his partner, Donna Wilkinson, on the morning of April 7.
She had gone to bed around midnight “worried about him”. She had woken up and gone downstairs to find him hanged.
Paramedics attempted to revive him, but a short time later he was pronounced dead.
A statement from Mr Tierney’s GP said he had suffered from anxiety and depression after his mother’s death and had been referred for appropriate services.
In 2016 he was seen by the neuropsychology team. He was prescribed pregabalin and then gabapentin for headaches after the head trauma he suffered as a child.
He was referred to the community mental health team in 2019 because he was struggling with his mental health.
Mr. Tierney was then referred to the crisis team in February 2021 following the second suicide attempt.
He was seen by the crisis team on February 27, March 1 and March 5, and was then released from the service on March 7, back to the community mental health team.
Tierney’s risk was assessed by the community mental health team on March 13 and he was deemed to be at “medium risk” for suicide.
A statement read on behalf of the Allerdale Community Mental Health Team said he had a history of alcohol abuse and had been unemployed since he was 18 years old.
He liked to go to the gym for his mental health, but had not been able to due to the lockdown.
The community mental health team had trouble reaching Mr. Tierney by phone on several occasions in the weeks before his death.
Miss Tierney said this was because her mobile phone was broken.
The inquiry heard evidence from David Muir, director of North Cumbria at the Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust.
A serious incident investigation was carried out following the death of Mr. Tierney.
Coroner Kirsty Gomersal asked if the investigation found a problem with Tierney being released from the crisis team after the second suicide attempt.
Mr Muir said: “I think in terms of discharge, the team identified alcohol concerns, then moved on from that, when things settled down, I was safe to be discharged, with that review.
“He had been flagged for follow-up care. That’s what would be expected under the circumstances.”
The investigation heard that a multi-disciplinary discussion was held on March 6 and the risk of Mr. Tierney was reviewed. He was deemed eligible for discharge from the crisis team.
Ms. Gomersal also questioned why Mr. Tierney was not fit for a secure mental health unit when he was taken to hospital by police.
Muir said Tierney had been seen by two doctors, a mental health professional and a social worker.
He told the inquest: “The doctors made that judgment at the time. I didn’t want that hospital admission.”
“If someone needs to be admitted, the appropriate recommendations will be made. In this case, it was not sectioned.”
Mr. Muir said he was satisfied that Mr. Tierney’s care was in accordance with trust policy.
Ms. Gomersal asked if Mr. Muir had any concerns about the plan of care developed by the crisis team for Mr. Tierney.
Muir said that the plan of care was satisfactory but that it was not being recorded correctly.
The coroner asked if a home visit could have been carried out when the community mental health team had had trouble getting in touch with Mr Tierney.
Muir responded, “That maybe could have been an option. There’s some risk in going unannounced alone. Maybe that could have been an option if they felt it was necessary.”
The investigation had shown that the risk assessment was being updated with a risk score, but the description was not being updated.
While issues were identified, they were not found to have contributed to Mr. Tierney’s death, but were “flagged as there could be potential issues with other cases.”
The inquiry heard that a number of changes had been made to address the issue.
Risk assessment has been completely replaced and is integrated into patient care records rather than being a stand-alone system. Regular audits are conducted to ensure clinicians are properly updating the system.
The investigation also showed areas of good practice in Mr. Tierney’s care, as the team met turnaround times and set collaboration goals with Mr. Tierney.
Ms. Gomersal told Mr. Muir that Mr. Tierney’s family felt that he had been neglected by mental health services.
Muir said: “I don’t think he was neglected. He had access to services.”
Coroner Kirsty Gomersal concluded that Mr. Tierney committed suicide and that the cause of death was hanging.
In her closing statement, Ms Gomersal said: “I express my deepest condolences to all of you.
“I appreciate that today’s investigation cannot change your opinion that Aarran was defrauded. I hope you will have the opportunity to meet with the Trust at a later time.”
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