A hospital's 101 calls to police to report a depressed man had gone missing went unanswered for hours, an inquest has heard.
Tragically, Piotr Andrzejczak, 25, was found dead in dense woodland nine days after walking out of the emergency department at Royal Oldham Hospital on July 14, last year.
On that day, hospital staff tried to report him missing from 3.45pm using Greater Manchester Police's 101 line, assistant coroner for Manchester North Matthew Cox was told.
READ MORE: Body found in search for missing man, 25, last seen at Oldham Hospital
The initial call was held for 45 minutes, but this was disconnected when staff saw police officers in the emergency department attending another matter.
When told of the difficulties, the police officers said they would report Piotr missing.
But eventually, they told the staff they could not make contact either and advised the nurses to keep trying 101.
It took until 9.58pm for the staff to get through on the 101 number.
By this time, Piotr's desperate family had visited Oldham Police Station and themselves reported him missing at 8pm, still more than four hours after he disappeared from the hospital.
Piotr had initially gone to the hospital after telling his mother, Anita, to get out of the house they shared in Blackstone Road, Rochdale, because 'the doctor was coming to kill her'.
The following day, he told his sister Alex he was hearing voices and that someone was going to kill him.
Alex said she persuaded Piotr, a packer at a car parts factory, to go with her boyfriend Nathan to the emergency department at the Royal Oldham. They arrived at 2.42pm.
"Because of Covid restrictions, Nathan was told he couldn't stay and was asked to leave," she said.
"Staff said they would get someone to sit with him while he was waiting to be seen," she said.
Police evidence revealed Nathan left the hospital at 2.46pm.
After that Piotr was seen on CCTV leaving the waiting room at the hospital's urgent treatment centre, walking round in circles talking on a mobile phone before exiting the hospital at 3.22pm.
Alex had called Piotr several times and she said he assured her he was OK, and that he was waiting to be seen.
But on the final occasion, it seemed to her he was outside walking. After the call ended, she was unable to get through again.
Alex called the emergency department and she was informed Piotr had left the hospital and that they had contacted the police, she said.
Piotr's family visited the hospital and searched the grounds to try to find him, but he was nowhere to be seen.
It was then that they went to the Oldham Police Station, where offcers said there had been no report of Piotr being missing, contrary to what they had been told at the hospital.
Detective Inspector Richard Arthern told of the ensuing search for Piotr.
There were reports of him being seen near Oldham Athletic's football stadium, but he was eventually discovered by a dog walker in dense woodland at a ravine near Cinderhill Lane, Oldham, on July 23.
Pathologist Dr Emil Salmo said the cause of death was hanging.
Jason Unsworth, business lead for contact acknowledgment with GMP's 999 and 101 call handling services said July 2021 saw exceptional demand on calls, 'breaking all previous records'.
"The country was coming out of Covid restrictions and people in the country were enjoying themselves," he said. "There was a heatwave and there was the European Championships."
He also said that 16 per cent of the 999 call handlers were off work because of Covid or self-isolating.
Alex said her brother was depressed because his application to join the police force had not been successful after studying public services at Hopwood Hall College for two years.
He was also upset about the breakdown of his parents' relationship and separating from his girlfriend.
Piotr went to his GP and was prescribed anti-depressants and had referred himself to the mental health support group MIND, recognising that he needed treatment.
However, there was no response to his referral request until after his death.
"Piotr said he was having suicidal thoughts, and that he needed help, but wasn't specific about what he meant by that," she said.
"He had been depressed for some time [12 to 18 months] but it got worse since the application to join the police had failed."
It was only shortly before his attendance at hospital that his family were aware of the suicidal thoughts, the inquest was told.
Concluding that Piotr's death was suicide, Mr Cox said: "The family's concerns in relation to what happened is that staff at the Royal Oldham Hospital did not look after him or allow a family member to remain with him.
"I can understand that concern. They will always think, what would have happened if Nathan had stayed with him?
"Would he have received treatment , would this have changed the outcome?
"But I have to reach a conclusion on whether different action would've changed the outcome and on the balance of probabilities and not on what it might've done.
"The evidence is unclear about whether Nathan left hospital to move his car, as reported by police, or whether he was asked to leave due to Covid restrictions."
He went on: "We've also heard evidence about the contact the hospital made with the police.
"I am also unable to say whether earlier contact with the police, for example making a 999 call [instead of 101] would've changed the outcome."
