A lack of hospital beds was the “root cause” of the death of a missing man whose body was found five months later in a river in Chester, an inquest heard.
The day before Gary Ronald Cooke vanished on January 9, he had gone to Wrexham Maelor Hospital for help after hearing voices due to taking so-called legal highs.
He was told there were no available beds for patients with mental health issues in North Wales and the nearest one for the 34-year-old was in Macclesfield, more than 50 miles away, an inquest in Ruthin heard.
Speaking at the hearing his dad Ronald Cooke said he believed if there had been a bed “he could still be alive today”.
A post mortem examination found injuries to his son’s nose and head, but because his body was so decomposed it was impossible to tell when or how he died and when he entered the water.
At the Maelor Mr Cooke, who lived in a flat at the Sandycroft Dry Cleaners, was assessed and given medication, the court heard.
He was not ill enough to be sectioned and was asked to come back at midday on January 9 and if there were still no beds available, he would be given home treatment.
But the computer operator never came back and was reported missing, sparking a major search.
A member of the public spotted his body months later on June 6 in the River Dee at Saddlery Way, Chester.
Mr Cooke’s death prompted an investigation by Betsi Cadawaldr University Health Board (BCUHB) chiefs.
They admitted the lack of beds was a “root cause” of his death and are drawing up a strategy to provide better mental health care.
That includes increasing beds for patients, working with local authorities to find accommodation to house them, setting up safe havens, “crisis cafes” and 24/7, seven days a week, mental home team support.
Dr Javier Rodriguez, BCUHB director of mental health services in the east, told the hearing the new system should be ready to go in April and rolled out over five years.
“A root cause here (in Mr Cooke’s death) is a lack of a local bed and that was something that clearly was one of our main concerns,” he said.
“This is something that has been high on the agenda for some time and we know that resources have been working beyond capacity.”
Assistant Coroner for North Wales East and Central Nicola Jones recorded an open verdict.
She said she was satisfied by the health board’s efforts to improve its service.
Ms Jones added that the inquest could be reopened if more evidence comes to light on how Mr Cooke died.
Speaking after the hearing Andy Roach, BCUHB’s executive director of mental health and learning disabilities, said: “We offer our sincere condolences to Mr Cooke’s family, and fully accept the coroner’s findings.
“We are working to better meet the demands on our mental health services.
“We welcome the coroner’s recognition of our work to meet bed capacity needs as part of our mental health strategy.”