Greater Manchester Mental Health has made changes to its practices after a man died shortly after being discharged as an inpatient.
Damian Naskrecki was found hanging in woodland at a Darcy Lever nature spot on September 25 last year.
It was later discovered he had cocaine, amphetamine and methamphetamine in his system.
An inquest into the death of the 36-year-old took place at Bolton Coroners Court this week.
The court heard he had been involved extensively with mental health services.
He was detained under mental health legislation in December 2021 after he attempted to take his own life and released the same month.
And in July last year he was admitted as an inpatient first to Wythenshawe Hospital and later the Royal Bolton Hospital due to mental health difficulties.
He was released to be supervised by the home based treatment team in north Manchester.
He was sent initially to a hotel with the plan that he would find his own accommodation after seven days.
Tracey Smith, from the home based team, saw him after a week.
She said there was no concerns and he was going to go to the Booths Centre to get accommodation sorted once she left.
She said the check up period “can be extended if we feel the need to do so” but said Mr Naskrecki was “really well.”
Mr Naskrecki then checked himself into A&E at the North Manchester General Hospital on September 17.
The next day he was assessed and passed onto the Mental Health Homeless Service.
However it emerged he was not suitable for them as he had already engaged with services.
His case was passed onto the Community Mental Health Team but after a five day delay.
On September 23 he visited former partner Natalia Stanczuk and changed his clothes and to have some food.
She was asked what his mood was.
She said: “He has been saying he has nowhere to go.
“He had been having a breakdown and was mentally not stable.”
A member of the public found him deceased in the secluded wooded area.
Team manager for patient safety, Mark McCann carried out a report into how mental health services dealt with Mr Naskrecki.
He said in the circumstances where he was visited by the home based team they would look at history as well and present mood.
He added there were now five more people working for the Mental Health Homeless team so wrongfully sent referrals would be passed on quicker.
Coroner Stephen Teasdale said he could not be sure that Mr Naskrecki, of no fixed abode, had intended to take his own life.
He recorded a narrative conclusion, which said: “He was found on September 25.
“His history is important.
“He has a history of mental health problems, substance abuse, self harm and psychotic episodes.
“He was found beyond resuscitation.
“The postmortem revealed use of cocaine, amphetamine and methamphetamine.
“The effect on the mental state of the deceased cannot be ascertained.”
If you're struggling with your mental health or are in crisis, you can call Samaritans free of charge on 116 123 - they're available 24 hours a day, 365 days a year.
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