On the Sth April 2013 commenced an investigation into the death of Gareth Mark Slater date of birth 11.04.1982. The Investigation concluded at the end of the Inquest on the 29th January 2014. The conclusion of the Inquest was that Mr Slater had died as a result of 1a) Drowning 1b) Multiple Injuries II) Bipolar Affective Disorder. On the 31st March 2013 the deceased, who had a history of mental illness, was found in the River Medlock having apparently fallen from Bardsley Bridge. There was no evidence found of any intention t0 end his life_ The conclusion was an open conclusion.

Circumstances the Inquest heard evidence that the deceased had at the age of 19 developed a severe and enduring mental illness and had been diagnosed with Bipolar Affective Disorder As a result of this he had spent substantial periods of time in hospital including a five year admission from 2007 until 2011, In addition to his mental illness the deceased also used alcohol and illicit substances which could impact on his mental health. It was noted at the Inquest that self-harming behaviour and suicidal ideation was not a feature of Gareth's mental illness_ In 2011 he had been released from hospital, low secure services, under the terms of a Community Treatment Order into supported accommodation. Within 5 weeks the deceased had been readmitted to hospital. It had been envisaged that he may need to be readmitted to hospital but that this would be for short periods of time. The deceased was readmitted into Oldham in-patient services. Following his admission there was a difference of opinion between his Clinical Team as to whether Gareth required admission back to Iw-or indeed medium-secure services or whether he could be released again on the Community Treatment Order: This impasse lasted until November 2012, some 16 months after his readmission. It was unclear from the evidence exactly when the decision was taken that Gareth would be discharged under the Community Treatment Order; however on the Sth October 2012 Gareth signed a tenancy for a flat with the help of his STAR worker and on the 22nd October 2012 Gareth's care was transferred to a different Consultant he was moved to a different Ward. In addition on the 8th October 2012 his case was given to a new care CO-ordinator. Following a Professionals meeting on the 23rd October a date of the 6th November 2012 was set by the Consultant Psychiatrist as the date of Gareth's and and discharge from hospital, Gareth was subsequently discharged and moved into his own accommodation. Following his discharge Gareth attended A&E on one occasion on the 1Sth February 2012 when he indicated that he had been using illicit substances, not complying with his medication and felt that he 'couldn't cope He was assessed and it was noted that there was no deterioration in his mental illness. He was not readmitted. On the 18th March he met with his Out Patient Consultant Psychiatrist who renewed the Community Treatment Order; In the weeks leading up to his death he had admitted to his family and his Psychiatrist that he was having some difficulties with people using his flat, On the 29th March he had been collected from his flat by his family and had stayed at his Grandmother's house: He left her house on the morning of the 30th March: It has not been established where he was until he was found 24 hours later on the 31st March; There were no witnesses to the incident:

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action: live carry The