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A coroner has written to Greater Manchester Integrated Care Board (ICB) voicing concerns over long wait times for mental health therapy support following the death of a patient who had taken too many prescribed painkillers.
In a ‘Prevention of future deaths’ (PFD) report, issued to Greater Manchester ICB on 16 April 2025, Alison Mutch, senior coroner for Manchester South, raised concerns about the wait times for mental health support following the death of patient Robert Smith.
According to the PFD report, Smith had a history of mental health difficulties and was on the waiting list for interpersonal psychotherapy (IPT). During an inquest, it was revealed that he had been assessed as “someone who would gain a real benefit” from IPT.
However, he had not started it at the time of his death owing to a significant waiting list with demand “far higher than the capacity”.
The report said the evidence at the time of the inquest was that the waiting time for IPT was 12 months on average “due to the ongoing demand against commissioned capacity”.
On 25 October 2024, Smith was found unresponsive at his home address.
Police found no suspicious circumstances or evidence of third-party involvement in his death. A post-mortem examination found above therapeutic levels of his prescribed medication in his system.
The inquest concluded accidental death, with a medical cause of concomitant dihydrocodeine and pregabalin toxicity.
According to the report, Greater Manchester Mental Health NHS Foundation Trust indicated that unless additional services were commissioned, it could not increase its provision, and waiting lists “would remain high”.
A spokesperson from NHS Greater Manchester ICB told The Pharmaceutical Journal that it was unable to comment “until we have responded to the coroner as per accepted practice”.
The ICB must respond to the report by 5 June 2025, with details of action taken or proposed, including a timetable or an explanation of why no action is proposed.
PFD reports are legally required from a coroner when it is believed that action should be taken by a person, organisation, local authority or government department or agency to prevent future deaths.
In April 2024, The Pharmaceutical Journal reported that more than 100 pharmacists had been recruited into community mental health teams across 36 NHS trusts in five years.
