THE mother of a psychiatric patient, found dead on an embankment a day before he was due in court, claims hospital staff could have done more to prevent his death.

Kathleen Holmes quizzed witnesses at an inquest into the death of her son, David Holmes, a former patient at the Royal Bolton Hospital.

The inquest heard how Mr Holmes, 33, of South Street, Bolton, was found dead near a disused railway line by Farnworth man Roland Anderton, who was walking his dogs on the evening of August 21, 1997.

Coroner Martin Coppel heard how Mr Holmes was an in-patient on K2 ward by a bail order after being found guilty of assault by Bolton Crown Court.

Fears

A report was being drawn up for the court before Mr Holmes, who had a history of personality disorders, alchohol abuse and depression, was sentenced.

He was being treated as a voluntary patient, Mr Coppel was told, which meant he was allowed off the ward on a regular basis.

The inquest also heard how Mr Holmes had expressed suicidal intentions over fears that he would be sent to prison.

At 3.50pm on the day of his death, a friend of Mr Holmes, with a "wild look about him", appeared at the hospital's breast screening unit. Receptionist Maureen Yearn said the man was asking for help for his friend David, who was "off his head". Kathleen Holmes asked the receptionist at the inquest why she did not help.

The receptionist replied that the man became agitated at the mention of security being called, saying David had a fear of uniforms. The inquest was told that the receptionist phoned K2 to report that there was a disruption.

The coroner was told how "minimalised staffing levels" on the ward meant no-one was available to bring David back.

Staff nurse Sara Johnson said: "I wouldn't like to guess how long it would take to walk down there and bring someone back. David had a history of aggressive behaviour. I would have been very reluctant to go ."

Mrs Holmes asked staff nurse Johnson why security was not called to bring her son back. She replied: "I thought they had been phoned. I expected security to be bringing him back."

David's disappearance was reported to police at 5.30pm. His body was found face down on an embankment near Minerva Road at 8pm. A post mortem revealed high levels of morphine "frequently associated as fatal to non-heroine users". Alcohol and diazepam were also found in his body.

Mr CoppeI said David, facing a prison sentence the next day, took his last chance to have a good time and have some marijuana, "not knowing the effect it would have on him".

Recording a verdict of misadventure, Mr Coppel said the cause of death was a drug overdose, but he refused to be drawn on the hospital's actions.

After the inquest, Mrs Holmes said she had been forced to drop legal action against Bolton Hospitals NHS Trust because of the cost.

Although she did not believe the hospital had caused her son's death directly, they could have prevented it.

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