A mother whose 17-year-old son died after falling from the top of a car park says she wants "justice".
Stanislav Mucha had a history of mental health problems and had previously been sectioned under the Mental Health Act before his death in his home town of Bury in February last year.
Stanislav had been diagnosed with acute on-set psychosis but Rochdale Coroners' Court heard he had not shown any indication of self-harm.
The Manchester Evening News reports he died of “polytrauma” at Salford Royal Hospital on February 3 2021, a day after falling from a car park.
The court was told Stanislav’s friends were concerned by his behaviour when the Covid lockdown was first announced.
That, the court heard, was the start of a string of issues with his mental health.
A lack of communication in the build-up to his death was cited by senior coroner for Greater Manchester North Joanne Kearsley as an area of concern.
After being detained under the Mental Health Act in April 2020, Stanislav had displayed psychotic symptoms such as hearing voices.
A Mental Health Act assessment should have taken place on January 22, but due to Stanislav’s apparent lack of cooperation it was postponed until the day after he died - something the coroner criticised as none of the staff members there tried to ask permission to enter the house.
Ms Kearsley said there was no explanation for why that was done - and why standard practice was not followed.
Those issues will be included in a report which will look into ways the health services can prevent future deaths.
Speaking after the inquest concluded, Stanislav’s mother said: “I just want justice for my son. I believe more could have been done for him.
“All these children need help and these services should be speaking with them.
“They need to know what is happening with these children. If they did speak with my son, he would still be here.”
Stanislav had been refusing to take his medication or speak to mental health professionals since returning from a three-month family trip to Slovakia, their country of origin.
“Having reached my findings I have to consider whether any of the failures caused or contributed to Stanislav’s death,” Ms Kearsley said summing up.
“One of the striking features of Stanislav’s illness is that it did not present overt explicit risks of self-harm.
“His diagnosis would always give rise to some risk of impulsivity but he had no known attempts of self harm.
“He was not someone who expressed suicidal thoughts, albeit there had been no attempt to explore this since his return from Slovakia.”
Ms Kearlsey went on to say that whether the mental health assessment on January 22 would have led to Stanislav being detained is unknown, which means there is no evidence to say he would have been in hospital on the date of his death.
When giving her conclusion the coroner was not satisfied that Stanislav intended the consequence of his actions and could not find any further evidence of suicide, so ruled that out.
Ms Kearsley gave a narrative conclusion: “He died as a result of catastrophic injuries sustained after he jumped from a sixth-storey car park. There was no evidence of his intentions and he had a history of psychosis.”
Clare Parker, executive director of nursing, healthcare professionals & quality governance at Pennine Care NHS Foundation Trust, said: “We offer our deepest sympathies to Stanislav's family for the loss of their much loved son and we are very sorry for what happened.
“We accept the conclusion of the coroner and we will learn from the recommendations made to us.
"We will be making improvements in how we work together with local authority teams to better help and support our patients.”
