A coroner slammed the 'suboptimal' care that a resident of a probation hostel received prior to his death. Craig Akhtar Bissa, 27, died while living at St Joseph's approved premises, in Eccles, on April 1 2019, an inquest heard.
Concluding a three-day hearing at Bolton Coroner's Court, assistant coroner for Manchester West, John Pollard found that Craig died as a result of misadventure, having mixed morphine, cocaine and buprenorphine. Prof Pollard also raised a number of concerns about the evidence he had heard over the course of the week.
Craig, originally of Rochdale, moved into the hostel in January 2019 after being released from Risley prison and probation case worker Jim Murray had told the court that it had 'never occurred' to him that Craig may have been using drugs. Prof Pollard described this as "naïve in the extreme" and added: "the protection and oversight needed and expected was short of being optimal or satisfactory".
On March 31, an ambulance had been called for Craig because he was ill but he refused to go to hospital, despite the advice of paramedics who attended. The court heard that staff were to check on Craig every 15 minutes and that three workers were at St Joseph's that evening - with part-time Philip Knight was deemed to be the most senior.
At 1am on April 1, Craig was found in his bed with patch of vomit near his head. None of the staff attempted CPR or used the hostel's defibrillator to try and resuscitate Craig, the inquest heard.
Mr Knight told the court that he had a mobile phone from the probation service kept in a bag for when he carried out checks, in case of emergency. Initially, Mr Philips believed he had no phone signal to call an ambulance, but then said he may have not known how to use the device.
He told the court he went down to the office to use the landline 'after a few seconds' to call 999 instead, taking instructions from North West Ambulance Service. An incredulous Prof Pollard described Mr Knight's evidence as 'incredible'.
He added: "His first aid training was out of date. His evidence suggested a less-than-competent regime at the premises."
Prof Pollard said he was also 'less than impressed' with the evidence of out-of-hours GP Dr Pramanik. She admitted that she decided against attending to assess Craig in person and suggested that he could have been sectioned.
The coroner told the court that Dr Pramanik's evidence demonstrated "little to no understanding of the Mental Health Act and Mental Capacity act". He added: "She accepted in retrospect that she should have gone to see the patient".
Following evidence from pathologist Dr Usha Chandran and forensic toxicologist Julie Evans, Prof Pollard recorded a medical cause of death as 'alcoholic fatty liver and combined effects of non-toxic levels of morphine, cocaine and buprenorphine'. He reached a conclusion of misadventure but told the court that he would not write a prevention of future deaths report, after hearing evidence that a review into the site's psychiatric offering is already underway.
