Key details missed before St Annes mum and son took their own lives

But key details about the extent of his mum's declining mental health were not passed on to the boy's metal health and social care teams, in the months before it was decided to discharge him back to her care.

Marshall Metcalfe, 17, of Heeley Road, St Annes, returned home to his mum in January 2020 and took his own life four months later, on May 7 2020..

His grief stricken mum Jane Ireland, 44, of the same address, who was described as a loving mother beset by severe mental health issues, took her own life just one month later..

Although there had been favourable reports about her progress, in reality she had been hearing 13 different voices, including that of the god Yarweh, had a number of hallucinogenic delusions about angels and had started drinking to excess.

At a joint inquest into the deaths of both Marshall and his mother, coroner Andrew Wilson is aiming to establish if key opportunities to help the pair were missed.

The inquest heard from Ms Ireland's dedicated mental health case worker, Zoe Cogle, who was a senior care coordinator with Lancashire and South Cumbria NHS Foundation Trust's Early Intervention Service.

Ms Cogle became Ms Ireland's mental health assessor in September 2017 following discharge from hospital after attempting two overdoses.

By December 2018 Jane Ireland's mental health had deteriorated and her mum, Patricia Ireland, was concerned by this and worried that she not been to collect her antipsychotic medication.

Ms Cogle was informed of this by email.

Asked by Claire Watson, counsel for the inquest if she raised Patricia's concerns with Marshall's social workers, she said she hadn't.

Asked why, she said: "I probably should have done, in hindsight."

In March 2019 Ms Ireland's daughter Holly had raised concerns that her mum's behaviour had become more erratic with the voices she was hearing, her alcohol intake had increased and Holly suspected she was not taking her medication.

Ms Cogle was asked if she had informed the team looking after Marshall at The Cove mental health unit, replying that she hadn't.

Ms Ireland was discharged from the Early Intervention Service in July 2019, after Ms Cogle left her post and Ms Ireland did not wish to have another person involved in her case.

This was a key development as she was no longer being seen by mental health professionals, but Marshall's social care team was not informed.

The inquest heard that when reporting back on the progress of Ms Ireland at team meetings, there had been an over reliance on Ms Ireland's own assessments of her mental health and compliance with medication.

Ms Irekand had been given an after care plan which included where she could get help if needed.

However, Sion Davies, for the Trust, suggested to Ms Cogle that in establishing trust and a good working relationship with Ms Ireland, that relationship could have been lost if she had pushed her too far.

Ms Cogle agreed.

Mr Davies asked her if it was the case that when Ms Ireland heard voices, they could be a comfort to her and would therefore not necessarily be flagged up as a risk of seriously declining health.

Ms Cogle said that was the case.

Proceeding