Coroner calls for mental health service changes after man's death

Max Harley Max Harley was found dead in his flat in June 2011

A coroner has called for a mental health partnership to review its policy after a man under its care died.

The body of Max Harley, 33, was found in his flat in Clifton, Bristol, in June 2011, three weeks after he was last visited by a mental health worker.

Mr Harley, who had bipolar disorder, had stopped communicating with staff from the Avon and Wiltshire Mental Health Partnership NHS Trust.

A trust spokesperson said "significant changes" had since been made.

Avon coroner Maria Voisin said she would write to the partnership asking for a policy review so practitioners were given help when a patient disengages with the service.

An inquest into Mr Harley's death at Flax Bourton coroner's court last month heard he had been sectioned under the Mental Health Act but had been discharged on appeal.

His family said he was supposed to be visited every day for 21 days by a mental health worker, but Mr Harley said he did not want any contact.

Staff visited intermittently on six occasions. He was last seen on 6 June, 21 days before his body was discovered on 27 June.

The coroner said there was no process in place to deal with patients who did not want to engage with staff and medication.

The Avon and Wiltshire Mental Health Partnership NHS Trust said: "We are considering how we can improve guidance, given that clinical judgements need to be made in each individual case in the circumstances that prevail at that time."

The inquest into Mr Harley's death returned a narrative verdict. It heard the cause of death was unascertained.

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