A CORONER said action must be taken to prevent future deaths after a man was found hanged at an NHS facility for people with mental health conditions and “various opportunities” to save him were missed.

Gareth Etchells-Height took his own life at Wainwright Centre in Sheffield in April 2022 and left several suicide notes.

An inquest heard the 42-year-old, who had Asperger's syndrome, was distressed as he was due to be discharged the next day and staff should have told him he could stay another week.

He had been sectioned by police at Sheffield station, with symptoms of psychosis and paranoia, and spent a month as an inpatient on a mental health ward at Northern General Hospital before he was transferred to the step-down facility in March 2022.

Following the inquest, Coroner Alexandra Pountney said he had been provided with inadequate care at Wainwright Centre – run by Sheffield Health and Social Care Trust – and “future deaths could occur unless action is taken”.

In a report, the coroner said there was “wholesale inconsistency” in Etchells-Height’s medical notes so he was seen by a series of healthcare professionals who “did not have an up-to-date understanding” of his condition.

The coroner stated his risk assessment was “redundant” because it had not been updated after his mental health deteriorated on April 7 in 2022.

“This impacted upon the ability of those caring for Gareth to identify and recognise changes in his behaviour that were triggers for acute mental health crisis or suicidal behaviours,” she added.

“In evidence it became apparent that the trust did not have a system in place for routinely checking and updating the risk assessments.”

The coroner also said his discharge report “was not fit for purpose” as it “did not contain details of his diagnosis or sufficient information about high-risk behaviours and triggers”.

She added: “There were various missed opportunities during Gareth’s care and his death was contributed to by a missed opportunity to communicate to him that he would not be discharged from the Wainwright Centre on April 25 in 2022.”

After the inquest, a statement released on behalf of Mr Etchells-Height’s family described him as “an incredibly special individual”.

It added: “He was an interesting person and had his special interests, which included buses, and could tell you anything about a certain bus, including its number, fleet, where its garage was situated and the type of engine it had.

“Notwithstanding Gareth’s neurodiversity, he worked in various jobs and was an intelligent and capable individual.

"His parents, Caroline and Michael, and brother Alex cherished him and miss him very much.”

A copy of the report has been sent to Sheffield Health and Social Care Trust, which must respond to the coroner by January 15.

A spokeswoman for the trust said: "We are deeply saddened by the death of Gareth. We always strive to give the best care possible to our service users and we welcome every opportunity to learn and improve the way we do things."

Man died at NHS facility in Sheffield after ‘various missed opportunities’