Michael Irlam

PFD Report Historic (No Identified Response) Ref: 2013-0224
Date of Report 4 September 2013
Coroner Andrew Bridgman
Coroner Area Manchester South
Response Deadline ✓ from report 17 October 2013
Coroner's Concerns (AI summary)
A significant 24-day waiting time between discharge from crisis mental health services and the first follow-up appointment creates a dangerous gap in care, risking patient abandonment.
View full coroner's concerns
Senior Clinical and Forensic Psychologist was engaged to conduct a Post Incident Review & Report: That report concluded at page 31 'Putting the patient first perceived gaps from the patient perspective' that a waiting time of 24 days between discharge from CRHTT the first appointment with IAPT could not be construed as a delay: This issue that arose at the Inquest hearing was the potential for a of abandonment because of the discharge without any knowledge of how long_it would be_ face and feeling before the next contact; of having to wait for the next stage/step without knowing when that would be. Mrs Irlam was clear that her husband deteriorated over this period despite the close, and loving, support provided by her and their family: That her husband found this & most distressing and difficult time_ Even if the Review Panel do not consider a waiting time of 3 weeks plus to be a delay for someone with mental health issues take the view that a waiting time of 2 weeks without knowing the next contact for helpltreatment will be is not appropriate My concern is for the welfare of other patients who will fall into this gap between treatmentslcounselling unlike Mr Irlam, do not have a close and supportive family and the effect on them: : (1) That if a follow-up with or referral to IAPT (or any other organisation) is deemed appropriate upon discharge from CRHTT then such an appointment should be arranged before or upon discharge. (2) (3)
Sent To
  • Improving Access to Psychological Therapies
  • Trafford Crisis Resolution and Home Treatment Team
Response Status
Linked responses 0 of 2
56-Day Deadline 17 Oct 2013
About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Report Sections
Investigation and Inquest
On 2Oth November 2012 an investigation was commenced into the death of Michael Stuart Irlam The investigation concluded at the end of the inquest on 8th August 2013. The conclusion of the inquest was Killed himself whilst the balance of his mind was disturbed Medical cause of death 1a Hanging
Circumstances of the Death
Mr Irlam was suffering severe depression and anxiety_ diagnosed mid-August 2012 He was in the care of his GP. After an attendance at A&E at Trafford General on 22nd August 2012 Mr Irlam became engaged with the CHRTT_ He was visited daily initially, later reducing to alternate days. On 2Oth September 2012 Mr Irlam took and overdose and was admitted to Trafford General overnight. He continued his engagement with the CHRTT_ He was discharged from CHRTT on 8th October 2012 He was told that IAPT would contact him by letter Almost 2 weeks passed before a letter came. He under took a telephone assessment in order to expedite his hoped for treatment as it was quicker than having a face to interview: He was advised to await another letter advising him of treatment: He did not get such a letter, simply a duplicate of the first letter: Mr Irlam then consulted and received treatment from a private psychologist: On 13th November 2012 Mr Irlam hung himself from the banister at his home while his wife was out: His daughter was at home
Action Should Be Taken
In my opinion action should be taken to prevent future deaths believe your respective organisations have the power to take such action_
Related Inquiry Recommendations

Public inquiry recommendations addressing similar themes

Service change continuity plans
Vale of Leven Inquiry
Care and discharge planning
Continuing responsibility for care
Mid Staffs Inquiry
Care and discharge planning
Follow up of patients
Mid Staffs Inquiry
Care and discharge planning

Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.