A coroner is to write to Greater Manchester Mental Health Liaison Team expressing concerns over 'system failure' following the tragic death of a 'loving and kind'  26-year-old.

Jean Fabrice Gueu, known as Fabrice, was found in his apartment on Portland Terrace on July 27 after his family could not reach him.

Bolton's Coroner Court heard that the day before he was found, Mr Gueu missed a doctor's appointment and calls from his GP and partner went unanswered.

His family doctor went round to his home after his shift in a bid to try and get hold of him and tried to contact the mental health team to find out if Mr Gueu had been assessed.

He was put through to the wrong department and kept on hold before being told to hang up and ring back.

The inquest heard that Mr Gueu had been suffering from mental health issues for some time and that he was ‘hearing voices’ and felt low.

A week before his death, Mr Gueu was admitted to A&E at the Royal Bolton Hospital after his family could not contact him for a few days.

Operation Manager for Urgent Care for Greater Manchester Mental Health, Jade Moore, confirmed that after being admitted, the GP details were not entered into the system, leading to a letter on Mr Gueu’s wellbeing not sent to his GP, who had been trying to obtain information in order to assess whether a welfare check was needed.

Following Mr Pollard’s questioning on whether there was a ‘system failure’, the solicitor for the Greater Manchester Mental Health Liaison team said the system was not a failure but rather human error.

The inquest was told: “The receptionist who did not record the GP details will be spoken to and wider admin will be trained.

“We will ensure there are no gaps in our service and will train admin on how to escalate it.

“The trust was not aware of the problem because it was not alerted to us that the GP letter had not sent.”

Mr Pollard challenged the Trust to say it was in fact a system failure if they did not know the letter had not sent.

The Trust explained that in seven days if a letter is not sent to a GP then the computer flags it, but admitted a human error was made.

The family of Mr Gueu paid tribute to a ‘kind’ and ‘loving’ man in the inquest.

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His partner, Abi Fatormah, with whom he shared a daughter with, said: “He was a kind person, very loving and always thought about others before himself.

“I think mental health is destroying a lot of families.

“We were going to get engaged, and he had a ring in his pocket.”

Mr Pollard concluded the cause of death as hanging and suicide.

He said: "Fabrice was seen by A&E staff and mental health team but no-one from either team took details of the GP practice.

"No letter was therefore sent to the GP.

"I find that this is is system failure with the mental health service.

"The letter should have been sent out, and seven days is too long of a time to wait as the doctor was waiting.

"The GP tried many times to contact Fabrice and even went to the extent of calling round at his address and knocking on the door, and that I find is beyond what would be a GP's duty."

To conclude, Mr Pollard said Mr Gueu took his own life.

He said: “I find that Fabrice did deliberately end his life.

“I record suicide and that is the conclusion I will reach today.

“I will write a letter of concern to the Greater Manchester Mental Health Liaison team for their system failure.”

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.