A mum whose son struggled with his mental health throughout his life told an inquest into his death she knew he would “never get old.”
Matthew McManus, 36, died after being struck by a train in November 2020.
He was previously a heroin user and was later diagnosed with a personality disorder, leading him to be in contact with a “significant number of agencies”.
In a damning report Anna Morris, assistant coroner for Greater Manchester South, said “no-one saw Matthew as the vulnerable adult he was”, the Manchester Evening News reports.
On the day he died, Matthew wasn’t registered as living at an address and had been staying with his friends in the Stockport area.
He contacted his substance misuse worker to find out when their next appointment was.
During that conversation, Matthew told her that he was thinking about going to buy heroin to end his life but they only reminded him of protective factors and of their future appointments.
Matthew then spoke to his probation officer who later sent him details of temporary accommodation in the North Manchester Area.
The coroner said the lack of coordination between agencies became “particularly concerning” when Mathew’s mental health declined – “making him more erratic and difficult to contact”.
The Salford Safeguarding Board spoke to Mathew’s mother, Doreen McManus, as part of its review.
The report read: “Doreen is struggling to come to terms with her son’s death and feels angry because she feels that Mathew didn’t get the support he needed with his mental health.”
It added she felt the professionals had judged her son, only seeing him as a “drug abuser with a criminal history”, not as a loving father.
The coroner said: “Mathew McManus had complex mental health and social care needs. He was in contact with a significant number of agencies, many of which focused on the risk that Matthew posed to others.
“However, the evidence before me, particularly that of the Salford Safeguarding Board, indicates that no-one saw Matthew as the vulnerable adult he was and addressed how his own complex needs were to be met, either through a Care Act assessment or any other means.
“Mathew did not have a single point of contact to help him understand and navigate the services being offered to him.
“This left already stretched services to do what they could to pull information together from their own resources or conversations with other agencies.
“Without proper co-ordination, there was no full information sharing, joint assessment, or joint planning of Mathew’s support, which meant there was never a full appreciation of the risk he posed to himself, and no real care plan was in place to manage that risk.
“Without a clear pathway for agencies to jointly assess and co-ordinate care in the case of adults with complex mental health and social care needs, I am concerned that future deaths will occur.”
Mathew’s sister, Tracey McManus, told the Manchester Evening News after the inquest that it was “hard” hearing that her brother had been failed during the five-day inquest.
“We [the family] understood that Mathew was failed, but to hear it from so many professionals is hard,” she said.
“He’s got two children who have got to grow up without a dad, which is not nice. They’re 14 and eight now,” Tracey added.
Tracey also paid tribute to Mathew after he died in November 2020.
She said: “First and foremost was a loving and devoted dad. His kids were his everything.
“But he was also a loving son, brother and uncle. He loved all his nieces and nephews. He was a proper Jack the lad.”
Greater Manchester Health and Social Care Partnership spokesperson said: “The death of Matthew McManus was a tragic loss for those close to him and our thoughts are with them at this difficult time.
“We will now carefully consider the coroner’s report and begin our investigations.”
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