A CORONER has criticised care bosses over 'individual and systematic failures' following the death of a former warehouseman.
Peter Shaw, who was living at sheltered accommodation on Sandy Lane in Accrington, was not seen for two days and later discovered dead in his room by his mum Annette Asher, an inquest heard.
Schizophrenia suffer Mr Shaw, 40, was being monitored by Hyndburn, Ribble Valley and Rossendale Complex Care and Treatment Team following his discharge from Royal Blackburn Hospital after concerns were raised over failures to take his medication.
Mr Shaw, who was taking a drug called clozapine, was last seen by Creative Support staff at the Sandy Lane complex on April 23 and was found dead at around noon on April 25.
Miss Asher told the hearing how she had contacted staff on April 21 following a phone call with Mr Shaw where he told he he thought he was 'going to die' and his 'heart was going to stop'.
However when staff spoke to Mr Shaw he say he had taken his medication but declined to show them and then did not answer his door.
The inquest was told how staff did not have the authority to enter Mr Shaw's room except in 'extreme circumstances' otherwise it could 'lead to a disciplinary'.
Coroner Michael Singleton, who presided over the inquest at Accrington Town Hall, ruled that on the balance of probabilities Mr Shaw died from clozapine toxicity and gave a verdict of drug-related death.
However he criticised Lancashire Care NHS over a 'lack of coordination' between the number of individuals and teams caring for Mr Shaw.
He also said there was an 'over reliance on a bureaucratic system' and that individuals seemed 'bound by protocols rather than any practical considerations'.
His sister Tracy Shaw told the inquest that she believed staff were 'more interested in following procedure than making sure he was okay'.
She said: “It's just really concerning my mum had to go and find him in that situation. Nobody has seen his medication and thought to investigate the matter further.”
Mr Morgan, a care worker at the complex care team, said Mr Shaw was well after being discharge from hospital and that the support put in place to monitor him was 'sufficient'.
The inquest was told how medication found in Mr Shaw's room were at the correct levels but a blood test taken earlier on April 16 showed his levels of clozapine were below the therapeutic range.
Mr Singleton concluded that on the balance of probabilities Mr Shaw took extra doses of medication between April 23 and April 25 to 'catch up' after he realised he had fallen behind and that it lead to his death.
He said he would consider in due course whether to write and issue a report to prevent further deaths.
Speaking after this inquest his sister Miss Shaw paid tribute to her brother.
She said: “He was confused and it was clearly an accident that could have been prevented.
“All the people who have mental health issues only want to be listened to and unfortunately he wasn't listened to effectively enough and neither was his family.
“He was well for ten years and was a success story. He was such a sociable and outgoing person with a fantastic sense of humour.
“There was not a single person who disliked him. It really is an absolute tragedy as he was a beautiful person.”
Lancashire Care NHS Foundation Trust said their procedures have been changed following a review of the case.
A spokesperson said: “This is a tragic case and our thoughts are firstly with the family and friends of Mr Shaw.
“The Trust has undertaken a review of services following the incident and has met with the family to discuss the findings of the review and the changes which have been implemented as a result.
“The Trust has co-operated fully with the coroner’s enquiry and will respond to any further questions the coroner has regarding the provision of services.”