THE Government has been urged to improve the care of mental health patients following the death of a man from Farnworth.

The coroner dealing with Stephen Leach’s inquest wants the health secretary to review the process of transferring medical notes for a patient who has been treated in an acute hospital to a mental health unit.

An inquest yesterday found that mental health wards either do not, or find it difficult to, get treatment notes from hospitals.

It follows the treatment of Mr Leach who had been at Royal Bolton Hospital A&E on August 7 before being moved to the Eagleton Ward in the Meadowbrook Unit, in Salford, where he died on August 14.

The unit, which operates under the Greater Manchester Mental Health NHS Foundation Trust (GM Mental Health), did not receive notes from Bolton about his treatment.

Coroner Alan Walsh raised concerns over the ward’s admissions process, the way staff made medical checks of new patients, recorded their findings and reported maintenance issues.

He said Stephen had problems coping with mental health issues, adding: “I am greatly saddened he should then die at a very young age in most unexpected circumstances.

“I hope some good will come from the lessons that will be learnt, although that is small consolation for his family.”

Mr Leach, aged 25, who was diagnosed with schizophrenia in 2010, went to Bolton A&E the week before his death with breathing problems and fast heart rate.

He was cleared to be transferred for further care at the Salford unit.

However, in the hours before the transfer his heart rate increased but no doctor was called.

Dr Damian Bates, a consultant at Bolton, admitted that Mr Leach, of Netherton Grove, should have been checked again.

He was checked by doctors at Salford who believed he was suffering from negative affects of schizophrenia and previous drug use.

However, no blood or heart rhythm checks were taken throughout his stay.

In the hours before his death he lay on the floor of his bedroom in front of the door and staff said he was talking but refused to get up without help.

They did not open the door for fear of hurting him. Just before 9am he was found unconscious and not breathing so staff forced the door and started CPR, but he was later declared dead.

During the course of the inquest the court learnt that staff could have opened the door outward but it was broken.

GM Mental health carried out an indepedent investigation and reported that it had made improvements, including further training, but would further investigate problems with maintenance. A post mortem examination found no cause of death, and Mr Walsh concluded an open verdict. He said issues raised may not have resulted in Mr Leach’s death but requested a review by the health secretary into the management of mental heath patient notes, as well as reviews into procedure by Royal Bolton Hospital and GM Mental health.