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NHS trust apologises for 'missed opportunities' to save suicidal father

Matthew Collings (54) was found hanged at Setley Pond, near Sway
Matthew Collings (54) was found hanged at Setley Pond, near Sway

AN ACUTELY depressed Lymington man who took his own life was let down by mental health professionals who failed to provide adequate support, an inquest heard.

Father-of-four Matthew Collings (54), was found hanged in woodland near Setley Pond, near Sway, by a dog walker on 25th February.

Despite being referred by his GP for urgent care, Southern Health NHS Foundation Trust failed to put a treatment package in place, for which it has since apologised to his family.

Winchester Coroner's Court heard how Mr Collings, who was a boat builder for 24 years, was diagnosed with anxiety and depression in October 2017.

His GP prescribed anti-depressants and by November that year he was feeling better. A statement from Dr Gareth Morris stated that Mr Collings had become unwell again in January this year and was hospitalised in February following an overdose.

A GP made an urgent referral to the community mental health team due to Mr Collings’ ongoing suicidal thoughts, and he attended an appointment at Waterford House in New Milton on 14th February with his sister, Jenny.

The inquest heard that Mr Collings was discussed at a team meeting on 21st February but for reasons unknown he had been downgraded from his “urgent” referral rating to “soon”.

This meant that the trust did not try to contact him regarding treatment until 25th February, by which point he had already died.

A 33-page report into the care Mr Collings received was compiled by Louise Earl of Southern Health NHS Trust, which is in charge of Waterford House.

The inquest heard that there were no notes to explain why his condition had been downgraded and there had been a lack of effective communication from the trust to Mr Collings, his family and GP.

There had also been a reliance on Mr Collings to contact services if he felt the need and a missed opportunity to refer him to the acute mental health team.

The report concluded: “Had Mat and his family received timely and effective support from Southern Health it is highly likely the outcome would have been different.”

The report added that “much learning” had been done since his death and a triage of care initiatives had since been developed.

Juliet Collings, who had been married to Mr Collings for 21 years, explained to the court that they had separated amicably the previous year but were still living together in the family home. He had also met a new partner, with whom he spent time with away from the home.

Mrs Collings said he had become unwell with anxiety and low mood around Christmas time but had been trying to cope through yoga and meditation.

She said: “He found his anxiety really debilitating. He would catastrophise things and he couldn't see any good in the future for him, despite telling him he had fabulous things in his life.

“Ultimately, the anxiety got a massive grip on him and it was too late. He was a desperate man at the end.”

Mrs Collings explained that although his anxiety reduced with his medication, it became apparent that he was suffering terribly with depression.

She said: “It wasn't until the last two days that I was seriously worried about his state of mind. He was just really flat. Mat was fed up – he didn't like suffering and it was as if he just couldn't bear it.”

The inquest also heard a statement from Mr Collings’ partner, Polly Jayne Newbury, who said he had struggled with pressures at work, his separation and that he also had financial concerns.

She said: “He was exhausted. His emotional pain was very deep.”

On the day he died she had been travelling home from a weekend in Cornwall and had not been able to make contact, despite calling him and sending text messages, she said.

As she approached Setley Pond she saw police vehicles and then recognised his car which was parked nearby. She explained to the police who she was and an officer confirmed he had died.

Pathologist Dr Vipul Foria gave the cause of death as hanging. Toxicology results showed Mr Collings had consumed no alcohol and had therapeutic levels of his anti-depressants in his system.

Recording a verdict that Mr Collings took his own life, assistant coroner Samantha Marsh said: “Mat’s struggles were acute and he was suffering terribly. I am satisfied that there were missed opportunities to support Mat and the wider family [and] the suboptimal service contributed to his death.”

Speaking after the inquest, his family said in a statement: “Matthew was a creative, energetic and adventurous man; kind, caring and loving to family, friends and colleagues.

"Although Matthew sought support from mental health services, it did not materialise quickly enough to help him.

“His untimely death is beyond sad and he is, and will always be, held dearly in the hearts of the bereft family and all those who knew him.”

The statement, issued on Tuesday which coincides with World Suicide Prevention Day, concluded: “The family wishes to urge you to listen to and look out for those who experience mental health difficulties and pain, particularly men, and respond quickly and robustly with compassion and determination to help them find active support.”

The Samaritans can be contacted on 116 123 or at www.samaritans.org.

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