The mum of a Salford man who took his own life said that she always knew that he would 'never get old' - but that professionals judged him and saw him as a 'drug abuser with a criminal history' instead of a loving father.
Mathew James McManus died on a railway line between Humphrey Park and Trafford Park on Monday, November 9, 2020.
An inquest into his death heard that the 36-year-old had 'struggled with his mental health throughout his adult life'.
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He had been diagnosed with a personality disorder and was in contact with a 'significant amount of agencies'.
Mathew had been a heroin user in the past but had not taken the drug for over a decade and was prescribed opiate substitutes.
But in a damning report, Anna Morris, Assistant Coroner for Greater Manchester South, said that 'no-one saw Matthew as the vulnerable adult he was'.
She 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."
The Safeguarding Board told the inquest that there was no one person or agency co-ordinating his support and care.
This meant that 'Mathew did not have a single point of contact to help him understand and navigate the services being offered to him,' Ms Morris said.
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.
His worker reminded him of protective factors and of their future appointments, the inquest heard.
Matthew then spoke to his probation officer, and repeated that he had thought about buying heroin to end his life, but he expressed an intention to keep attending appointments and said he did not now have any intention to buy substances.
His Probation Officer later sent him by text the details of temporary accommodation in the North Manchester Area.
Matthew also spoke to his mother. She was concerned about him because of texts they had exchanged over the weekend in which Mathew had indicated that he was low in mood and said that he was 'done'.
The coroner said, within the prevention of future deaths report, that the lack of co-ordination between agencies became 'particularly concerning' when Mathew's mental health declined - 'making him more erratic and difficult to contact'.
Ms Morris said: "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."
The Safeguarding Board spoke to Mathew's mother, Doreen McManus, as part of its review.
"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," the report read.
She said that she felt like the different agencies didn't talk to each other.
She also felt that professionals ‘judged’ him and that they they didn’t see him as a person who struggled with his mental health who loved his children - but as a ‘drug abuser with a criminal history'.
"I always knew my son would never get old and he would take his own life, it was a matter of when, someone should have helped him," Doreen said.
Ms Morris has addressed her report to the Greater Manchester Health and Social Care Partnership as well as Secretary of State for Health and Social Care.
They have been given 56 days to respond - unless granted an extension.
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. He wasn't an angel. He could have his moments.
"He loved collecting things, rubbish and bric-a-brac. He thought he could make anything from anything, but the thing was he never finished the job.
"He also loved motorbikes and was always out riding them and he liked gardening as well.
"But mostly he just liked spending time with his kids."
Mathew had previously worked as a van-loader, painter and decorator, factory worker, roofer and gardener but was unemployed at the time of his death, his family said.
A 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, in conjunction with other relevant organisations. A full response addressing matters within the remit of Greater Manchester Health and Social Care Partnership will be provided to the coroner, within the required timescales.”
The inquest into Mathew's death concluded that he had died from multiple injuries and by suicide.
