Micheala Finch: Prevention of future deaths report
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Date of report: 06/02/2026
Ref: 2026-0064
Deceased name: Micheala Finch
Coroner name: Timothy Brennand
Coroner Area: Manchester West
Category: Alcohol drugs and medication related deaths
This report is being sent to: Greater Manchester Mental Health | Greater Manchester Integrated Care Partnership
| REGULATION 28 REPORT TO PREVENT DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: Chief Executive, Greater Manchester Mental Health Chief Executive, Greater Manchester Integrated Care Partnership | |
| 1 | CORONER I am Timothy William BRENNAND, Senior Coroner for the coroner area of Manchester West. |
| 2 | CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 3 | INVESTIGATION AND INQUEST On 04 August 2025 I commenced an investigation into the death of Micheala FINCH, aged 59. The investigation concluded at the end of the inquest on 03 February 2026. Medical cause of death: 1a. Combined drug toxicity Conclusion of the inquest – Narrative conclusion: Michaela Finch died as the consequence of an overdose of her prescribed anti-depressant medications in circumstances where her actions and intentions remain unclear in the context of a recent and acute deterioration of her mental health driven by emotional dysregulation, disordered thinking, impulsivity and relapse into recent self-induced intoxication with associated intentional non-fatal overdose. |
| 4 | CIRCUMSTANCES OF THE DEATH The deceased had a medical history including mixed anxiety and depression with associated alcohol dependence syndrome. Her condition had been actively managed by local addiction services, primary and secondary mental health services, and her GP. Her relapse profile involved chronic alcohol misuse as a coping strategy for episodic emotional dysregulation arising from social stressors, physical health concerns, and personal circumstances. Previous relapses involved inadvertent self-harm via overdose of prescribed medications, with transient self-harming ideation. She had twice undergone inpatient detoxification/rehabilitation and had received support from the Home-Based Treatment Team. On 26 July 2025, following heightened anxiety and depression from recent social stressors, she relapsed into alcohol misuse. On the morning of 28 July 2025, she was admitted to Royal Albert Edward Infirmary, Wigan following an inadvertent overdose of Zolpidem. She refused a full mental health assessment but agreed to a CMHT referral and self‑discharged. Later the same day she re-presented with further deterioration in mental health and self-induced intoxication after prolonged concern for her welfare. She was referred to the Mental Health Liaison Team for suicidal ideation. A 30‑minute assessment deemed her to have full capacity. She disclosed involvement in a family incident leading to a safeguarding referral. However, her mental health deterioration, emotional dysregulation and irrational behaviour were not fully appreciated, being attributed instead to alcohol misuse. She was discharged with a conservative community‑based care plan and deemed not to meet the threshold for escalated home-based treatment. Whether this decision affected the outcome cannot be established. On 31 July 2025, in response to the safeguarding alert, she was arrested and interviewed by Greater Manchester Police, assessed fit for interview, and released with a caution. On 03 August 2025, after concerns for her welfare, relatives and emergency services found her collapsed and unresponsive at 4 Belvedere Road, Ashton‑in‑Makerfield. She was declared dead by paramedics. Toxicology revealed the presence of substances at medium toxicological significance, and alcohol plus other substances at low significance. CCTV confirmed her presence at home from 01 August, with her phone last used on 02 August 2025. The precise circumstances, timing or dosage of self‑administration could not be established. Although individually not fatally toxic, in combination the substances were sufficient to cause respiratory depression, loss of consciousness, hypoxic multi‑organ failure, and death—occurring on 02 August 2025. An undated handwritten note of intent was found, but evidence also showed several contra‑indicators to active suicidality, alongside anecdotal evidence of dysfunctional, irrational, and paranoid behaviour. Therefore, her intentions remained equivocal. |
| 5 | CORONER’S CONCERNS During my inquiry, matters giving rise to concern were identified. In my opinion there is a risk of future deaths unless action is taken. MATTERS OF CONCERN The deceased had a long‑standing diagnosis of mixed anxiety and depression and alcohol dependency. Evidence suggested she may have been suffering from a co‑occurring disorder (formerly “dual diagnosis”), warranting more active treatment, escalation, and a care coordinator. A recovery worker stated that Wigan addiction services receive numerous referrals involving service users with mental health needs requiring a care programme approach. Mental health provision was insufficient for such patients, and addiction services were perceived as an interim holding place for individuals with complex or nuanced needs. Neither the last assessing mental health clinician nor the author of the Rapid Review of Care identified: missed opportunities to appreciate her mental health deterioration the potential for a co‑occurring diagnosis the need for Home-Based Treatment Team referral. At least two family members had raised profound concerns about the deceased’s deteriorating mental state and paranoid behaviour to a Mental Health Team member. These concerns were not passed on to the assessing clinician. Communication was sub-optimal. Evidence suggested a lack of professional curiosity and confirmation bias regarding the cause of relapse—her alcohol misuse was not considered to be a symptom of mental health deterioration. Mental health staff stated that funding issues limit their ability to deploy escalated community care for patients who do not qualify for inpatient assessment or Home-Based Treatment Team referral. There is no mental health equivalent of “hospital at home”. Evidence confirmed a significant incidence of self‑harm or attempted self‑harm shortly after assessment and discharge from the Mental Health Team at Royal Albert Edward Infirmary, including self-discharges due to the challenging A&E environment. The evidence raises implications for: patient safety diagnostic accuracy risk assessment risk management safe discharge appropriate follow‑up. |
| 6 | ACTION SHOULD BE TAKEN Action is required to prevent future deaths, and you/your organisation have the power to take such action. |
| 7 | YOUR RESPONSE You must respond to this report within 56 days, by 03 April 2026. The coroner may extend the period. Your response must detail actions taken or proposed, with a timetable. If no action is proposed, you must explain why. |
| 8 | COPIES AND PUBLICATION A copy of this report has been sent to: The Chief Coroner Interested Persons: – Family – Kumar Family Practice It has also been sent to the Chair, Wigan Local Medical Committee. Your response will be sent to the Chief Coroner and interested persons, and may be shared with others who may find it useful. The Chief Coroner may publish this report or your response, in whole, redacted or summary form. You may make representations about publication at the time of response. |
| 9 | 06/02/2026 Timothy William BRENNAND Senior Coroner for Manchester West |