There was a "lost opportunity" in the months leading up to a young man's death.
Samuel Latham was 32 when he died under Southport Pier on Monday, October 24 last year. Merseyside Police were called to the seafront by a member of the public who found Mr Latham's body.
An inquest was held into the death of the support worker at Bootle Town Hall on Wednesday, September 13. The hearing heard that Samuel, from Southport, was diagnosed with bipolar disorder aged 19 and had struggled in the months leading up to his death.
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He would often struggle with his mental health and alcohol and drug use and had a "history of episodic low moods". Due to a deterioration in his mental health Mr Latham had been an in-patient in a psychiatric hospital in April 2022.
Following this, he was involved with mental health services. Doctor Rajeswari Venkatesan, a consultant psychiatrist who was treating Mr Latham as an outpatient, said at times Samuel would "discontinue medication" and before his death in September and October, he missed two appointments.
His parents, Sharon and Roger Latham, who attended the inquest, said they expressed concerns on several occasions regarding their son's mental health and poor compliance with medication. Roger Latham said at the hearing more should have been done to inform them and help their son with his mental health and drug use.
Paul Hart, clinical service manager at Mersey Care, said in order for someone to get treatment, they "have to want treatment".
When re-iterating their son's mental health should have been taken into consideration, Mr Hart added: "You're not the first person, nor the last to say this, unfortunately this isn't the way the mental health act works."
At the hearing, it was confirmed a risk assessment and care plan had not been updated and it "should have been". Mr Hart said there had been "lost opportunity" as the hearing also heard his family were not offered a carer's assessment as they "should have been".
The last contact with Mr Latham was at the depot clinic to receive his medication on October 20 where he had not expressed any suicidal tendancies.
Mr Hart confirmed a number of service problems at the time, including a lack of assessments and risks identified and the Care Programme Approach (CPA) was not fully adhered to as well as Mr Latham not being referred to substance misuse services – which he ended up doing himself.
The hearing heard several changes have been made since Mr Latham's death, including training and supervision and an increase in staff compliance. There is also a dedicated approach with dual diagnosis.
Recording a conclusion of suicide, coroner Julie Goulding said: "Notwithstanding the care and service delivery problems identified, and the increasing risks associated with his deteriorating mental health, at the time of Samuel’s tragic death, the real and immediate risk of Samuel taking his own life was not known about and again on the evidence available nor ought it reasonably to have been known about.
"Police were satisfied there was no third-party involvement in Samuel’s death. On the evidence available Samuel James Latham took his own life with the intention of doing so."
Sharon and Roger Latham had previously spoken of their "much-loved son's" battle with the condition. His mum said: “He lived with us and he was very much loved.
"He just unfortunately had bipolar. Samuel was a support worker and he loved looking after people with dementia. He also looked after people with learning difficulties.
"He would take his guitar in and sing to them and he was a lovely guy."
Roger added: "As a care worker, he was such a caring young man, and we have heard some lovely stories about what he enjoyed doing. He would write songs and sing them in local bars and that’s where a lot of people met him."
- For help and support for your mental health, you can contact Samaritans (116 123) operates a 24-hour service available every day of the year.
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CALM Campaign Against Living Miserably (0800 58 58 58) is a leading movement against suicide. It runs a UK helpline and webchat from 5 pm to midnight 365 days a year for anyone who has hit a wall for any reason, who needs to talk or find information and support.
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