A distressed father urged hospital staff to section his son after attempting an overdose - just one week before he ended his own life, a court has heard.
James Rice - known to his friends and family as Jim - was found dead at Close Park in Radcliffe seven days after being rushed to hospital by his father, Gordon Rice.
He told Rochdale Coroners' Court he had stayed with his 20-year-old son for five hours at Fairfield Hospital in Bury, but within an hour of leaving him in the hospital's care, Mr Rice had already been sent home.
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And one week later, his family received the heartbreaking visit from police officers about his death.
The court heard on Wednesday (October 27) that Mr Rice, a keen biker who was born in Salford but lived in Radcliffe, was a 'happy-go-lucky' character who had always seemed 'cheerful'.
But in the six months before his death, he would speak about wanting to end his own life, before changing the conversation as if it never happened.
Gordon Rice told the court: "It was like a switch - on, off. The next minute it was like it was normal.
"That's why I didn't believe it when he was saying it."
Jim Rice had struggled at school before starting a job as a packer for an agency, but after suffering an accident on a BMX bike the company didn't want him to return, the court heard.
He lived on benefits, but was able to get money from his father when needed, and he stayed in the family home until moving in with his girlfriend aged 19.
His father told the court that Mr Rice and his girlfriend had an 'on and off' relationship - and that he would often text him, asking to be picked up with his belongings, only to later change his mind.
The court heard that Mr Rice's family believed he may have had ADHD, and he was tested for it last year, but never had the result before his death.
A statement from his GP confirmed that Mr Rice had been referred to mental health services in November 2018 and reported the same issue again in May 2019.
He was prescribed medication last year, and this was believed to be working until earlier this year, when Mr Rice attended A&E on February 24.
Mr Rice was seen by Florence Makurira, who works in the mental health liaison team at Fairfield Hospital.
She told court that he had walked out on her during his assessment, before returning with his partner and talking about resolving 'anger management issues'.
Mr Rice complained to his GP about his medication not working in April, and the dosage was increased, before raising the issue a month later when the prescription was switched.
He attended A&E twice in three days in May for injuries, before returning on May 17 after attempting an overdose.
Mr Rice's father took him to hospital and told both the receptionist and a triage nurse that he believed his son should be sectioned under the Mental Health Act, the court heard.
His dad stayed with him for five hours before leaving Mr Rice at the hospital, where he was again assessed by Ms Makurira.
She told court he was displaying a 'fleeting suicidal ideation' but had no signs of psychosis or acute depression, and was able to make his own decisions.
Ms Makurira said Mr Rice was deemed low risk to himself or others, and claimed he appeared 'tranquil'.
He was referred to a remote mental health service set up during the pandemic and told to expect a call within 24 hours - which was an assessment Mr Rice agreed with, Ms Makurira said.
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Gordon Rice, alongside Mr Rice's mother and grandmother who were also in attendance, shook their heads at Ms Makurira's testimony and expressed their disbelief that he had been allowed to leave hospital so soon.
He said: "I told both of them - the receptionist and triage - that he wanted to die.
"And then within 30 minutes of me leaving hospital, he was sent home."
Ms Makurira added: "There were no grounds to keep him in hospital. He did not meet the criteria of being in hospital."
Margaret O'Neil, head of quality for mental health services in Bury at Pennine Care, conducted a review of Mr Rice's case at Fairfield Hospital and found the trust's response to have been 'appropriate'.
She told the court that in February, Mr Rice had denied he had been self-harming and said his main issue was anger management, and said that on May 17 there were 'no concerns with Jim's capacity'.
She added: "There were no identified concerns [with the hospital's actions]. The actions taken were in line with the expected standards."
Gordon Rice told the court that he had spoken to his son in the days after May 17, but he never mentioned the attempted overdose.
In the early hours of May 24, he received a call from his son asking to pick him up from his girlfriend's house.
The court that the pair went for a drink at McDonald's, before Mr Rice asked his dad to drop him off at Tesco in Whitefield to meet a friend.
Later in the morning, his dad received a phone call from police, before officers arranged to turn up at his home - where they told Mr Rice's family about his death.
DCI Ian Partington, of Greater Manchester Police, told the court that Jim was found hanged at around 5.20am by a dog walker in the park.
First response attended the scene and an ambulance was called out, but Mr Rice was pronounced dead at the scene.
Matthew Cox, assistant coroner for Greater Manchester north, ruled that his death was a result of suicide and gave the cause of death as asphyxiation.
On the issue of Mr Rice's appearances at Fairfield Hospital, the coroner concluded that he could not see evidence of any 'omission or lack of care that caused or contributed' to his death.
He added: "I do appreciate that the family will always have concern about what would have happened if he had been admitted to hospital on May 17.
"I clearly believe on the basis of the evidence that the deceased did intend the consequence of his actions in taking his own life on May 24."
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