A FATHER who suffered with mental health issues was found hanged at his Westhoughton home, an inquest heard.
Recording a conclusion of suicide, assistant coroner Simon Nelson said that "no one was given any indication at all of the events that would unfold."
Dad-of-one Ian Walsh, aged 29, was suffering from a depressive illness and had a medical history of anxiety.
Father Darrell Walsh, from Daisy Hill, said: "Ian was very soft, kind-hearted, a people-pleaser, and he wanted to make friends with everybody.
"He worked very very hard and very long hours. The rest of the time, he was a family man."
Bolton Coroners Court heard that there were several issues which "pushed Ian over the edge", including dismissal from his job as a sales manager in June 2017, and his social use of cocaine which caused arguments within his relationship.
Mr Walsh Junior moved in with his parents in the summer of 2017, where they managed his care and took him to regular GP visits.
His GP, Dr Edward Gillooly, from the Unsworth Group Practice, said: "There was nothing from the way he presented to myself that he was going to undertake what he did the following week."
In August 2017, Mr Walsh Junior made an attempt on his life which left him with a broken back and pelvis.
He received visits from the Bolton home-based treatment team until October 16.
Mr Nelson said: "You had concerns as to the competence and qualifications of those who were providing that help.
"You felt that the questions they were asking of your son were not helpful."
In October 2017, Mr Walsh Junior had his first session with the mental health team from Bolton but family described a "marked deterioration" from November onwards.
Mr Nelson said: "He became quieter and was spending more time alone or in his room.
"Your wife suggested reviewing his medication and requested a meeting with a psychiatrist.
On December 4 Mr Walsh Junior attended an assessment with mental health practitioner Damon Flannery, of Bolton's assessment service.
Mr Flannery said: "He portrayed it as though it had gone well.
"Everything he said, I believed.
"There was no indication to suggest that he was having suicidal thoughts."
It was Mr Walsh Junior's partner, who he met 13 years ago, who found him hanged at his home in Leigh Road, Daisy Hill, on December 14, 2017.
Coroner Simon Nelson said: "I cannot imagine the hurt that family members will have experienced during the past few weeks and months.
"Those who have been present today have heard of the disappointment on the part of the family as to how their son and partner Ian was cared for during the last few months of his life.
"The system is never perfect and there is always room for improvement. From what I have heard, the system is in the course of improvement.
"There are signs he was not being completely upfront with the professionals who were endeavouring to assess him.
"Contrary to what he had been expressing in those consultations, was the fact that, sadly, he still had access and was still using both potentially prescribed but also unlawful drugs, namely cocaine and Diazepam.
"No one, certainly not those who are the closest to him, no one was given any indication at all of the events that unfolded.
"I don't believe there would have been any basis on December 4 or 8 for Ian to have been compulsorily admitted or sectioned.
"What I do hope is that the trust and the family will meet when the time is right."
Greater Manchester Mental Health NHS Foundation Trust said that it had updated its referral process so that in an emergency case an assessment would be carried out the same day, and calls would be made to carers, family members and welfare officers if no contact could be made.
Anyone in emotional distress, struggling to cope, or at risk of suicide should call the Samaritans free helpline on 116 123 or email jo@samaritans.org.
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