A coroner has raised concerns after the death of a headteacher who died last year following a battle with his mental health.

Benjamin Sulzbacher, 48, described as an “incredible role model”, was found dead at Philips Park in Prestwich on September 27 last year.

His death came just days after he was discharged from the Priory, a private hospital in Altrincham, which provides inpatient mental health services.

An inquest at Rochdale Coroners’ Court heard Mr Sulzbacher, who was appointed as headteacher at Manchester Mestiva School in Prestwich in 2011, began to struggle with depression and anxiety in February 2021.

His son-in-law Alex Whittler said Mr Sulzbacher had been “struggling” in the months before his hospitalisation and this had been linked to stress at work and a fear of losing his job.

The court heard that in August last year, Mr Sulzbacher had threatened to take his own life and his family had seen him with a rope, which he had put in the back of his car.

He was later admitted to the Priory on August 26, where he spent three weeks as an inpatient.

Due to the only available acute inpatient bed being in the South, his family had funded a private admission at the hospital.

But on August 29, Mr Sulzbacher’s brother informed his family that he had concerns over the level of care and monitoring he had been receiving on the ward, after another ligature was found in his possession, which was reported to staff.

He was formally discharged from the Priory on September 19, which prompted further concerns from his family who say they were not told he was being discharged.

Recording a conclusion of suicide, senior coroner for Manchester North, Joanne Kearsley, ruled that Mr Sulzbacher had died from hanging, and said he had “intended to take his own life”.

She added that, despite concerns from his family, his discharge from hospital had been "appropriate" and he had "wanted to go home”.

Ms Kearsley told the court that "there was no reason that he had to be detained at that point" but said that the Priory should have given his family more information about home-based treatment.

The court heard if a referral had been made to mental health NHS trust Pennine Care’s home-based treatment team, they would have conducted a face-to-face follow up appointment within 72 hours, and if necessary, would have “remained engaged with Mr Sulzbacher for up to four weeks”.

The court was also told that the trust would have accepted such a referral even though Mr Sulzbacher had been a private-paying inpatient.

Following the inquest, Ms Kearsley filed a Reports to Prevent Future Deaths document raising concerns that “there was a lack of understanding from the Priory witnesses as to what the NHS community services could offer on discharge”. She added that “the court heard that the home-based treatment team was understood to simply be a ‘crisis team’, which was incorrect”.

Ms Kearsley also noted that it was “unclear to all services as to whether a private paying inpatient (who would have qualified for care under the NHS but due to bed availability went private) would be entitled to be referred to the discharge services offered by the NHS”.

She said that the NHS “provides more than the private sector in respect of community discharge packages and can be engaged with someone for longer”.

She added “face-to-face contact enables a better understanding of how a patient is actually presenting when considering their mental health”.

In response to Ms Kearsley’s report, the Priory said emails have been sent to its consultant psychiatrists to explain the “importance and professional requirement for them to maintain up-to-date knowledge and understanding of the services local NHS mental health community teams are able to offer”.

And all Priory hospitals have been asked to create a “local NHS mental health services directory”, which will distinguish between different teams and be updated annually.

The Priory said it is well-established in the majority of cases that private mental health inpatients “may access NHS services following discharge” but accepts it “would be helpful if options could be explained more clearly to patients and families so that they can make informed choices about aftercare”.

It has created a “standard operating procedure” which makes the “aftercare pathways clearer”, including provisions, which state that inpatients “are to receive a follow-up contact within 72 hours of discharge”.

But the Priory acknowledges “there will be occasions when an NHS referral is not achievable” for a number of reasons and in those circumstances a follow-up call will be made by the provider’s staff within 48 hours of their discharge.

NHS Greater Manchester said Pennine Care now has an out of area placement team who “help bridge the gap” between private hospitals and the trust. It added it would raise the case at quality assurance visits to providers.

Mr Whittler said his father-in-law “really loved and cared for us”.

He added: “He was an incredible role model and loved by everyone, he was an extremely special person, very genuine and real.”

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