A coroner has raised concerns over “gaps” in the processes mental health workers followed in their care for a dad who later jumped in front of a wagon on the M6.
But Simon Jones, who led the inquest into the death of company director Michael Garfin, 39, said he could not be certain, even if the “gaps” had not existed, that Mr Garfin would not have taken his own life.
Today, bosses at the Lancashire Care NHS Foundation Trust, who oversaw Mr Garfin’s care, said they had carried out a “thorough internal review”.
Football fan Mr Garfin took his seatbelt off while driving north with his wife Kirsty and two young daughters just past Charnock Richard services, near Chorley, on June 26 this year.
He then veered his Audi A4 estate across three lanes, smashing into a lamppost and uprooting a tree on the way to the family’s former home in Buckshaw Village, near Chorley.
After surviving the crash, Mr Garfin, who had been released from a mental unit 10 days earlier, jumped in front of an empty milk tanker.
Deputy coroner Mr Jones said he was concerned about the way Mr Garfin’s daily care package had been ended after one visit on his own say-so, as well as the follow-up meeting at Lancashire Care offices the next morning which was not attended by anyone who had been to see Mr Garfin.
The inquest at Preston Coroners’ Court yesterday also heard how part-time nurse practitioner Sam Cookson, who “signed off” Mr Garfin after the only visit on June 16, had been “quite rushed for time” that day and had not read Mr Garfin’s care plan.
Mr Cookson returned to see Mr Garfin following an assessment of the case by his manager John McKenzie, team manager at the Chorley and West Lancashire Crisis Resolution and Home Treatment Team.
But he arrived on June 26, the day Mr Garfin died.
The coroner said: “From my interpretation . . . it’s necessary to see an individual on more than one occasion, no matter how long that meeting is.
“Mr McKenzie, in my view, recognised that when he recognised it would be appropriate to have a further meeting.
“I’m therefore satisfied there are clearly gaps between what should have happened and what actually did happen with regard to the follow-up meeting.
“Having said all of that, I can’t be certain that anything would have been different had the gaps not existed – had Mr Cookson been aware of the plan, had he not signed him off – because it’s clear to me from Mr Garfin’s conduct on this day that he intended to kill himself.
“It would appear Mr Garfin was paying no regard to what that might have done to his wife and to his two young daughters.”
He also said he felt that in evidence given last week, psychiatrist Dr Bassem Naguib thought the importance placed on the views of the patients’ family was “an essential part of the on-going care”.
However, he said the discussion between health professional and sales manager Mrs Garfin had been “very limited”.
After the hearing, Patrick Sullivan, director of nursing at the Trust, said: “This is a very tragic case and our thoughts are with Mr Garfin’s family at this very difficult time.
“A thorough internal review has been undertaken and the Trust will consider the issues raised in the coroner’s court in order to take any actions required to help prevent such a tragedy from taking place in the future.”