A review has been carried out into how health teams work together, following the death of a west Cumbrian man.

Although organisations in Cumbria are not being blamed for the tragic death of Matthew Telfer, they have given assurances that they have reviewed protocols to make sure communications between them are a priority.

An inquest heard how Mr Telfer, 28, took his own life after battling a history of mental health problems and alcohol and drug abuse.

Mr Telfer had a troubled past, the coroner was told.

He was abused when he was younger which caused him to have flashbacks and his mental health suffered.

He also had problems with drinking and taking drugs.

Mr Telfer had been found hanged at an address in Whitehaven on July 22 last year.

Lisa Riley, substance misuse practitioner for Unity Drugs and Alcohol Recovery Service, told the inquest that Mr Telfer had attempted to kill himself on five previous occasions.

He received help from the Crisis team numerous times, the final time being last January.

He was discharged later that month.

Miss Riley said Mr Telfer, of Dent Road, sought help from Unity between last January and July, he suffered low moods and reported taking illicit drugs and drinking alcohol. He was discharged last July as he failed to attend numerous appointments.

She said: “He sounded really positive, very motivated. He was keen to be discharged. He seemed really confident about maintaining his abstinence.”

Shortly after, Mr Telfer and his girlfriend Chelsea Carr holidayed in Egypt.

She said: “We had a lovely holiday, it was really fantastic.”

She described her boyfriend, a former window cleaner, as an “outgoing lad” who could also be “quite shy”. She said his moods were “up and down”.

The inquest heard on Mr Telfer’s return home, he visited his GP and was set to be referred to the community mental health team.

On the day of his death, Miss Carr’s mother, Michelle Chambers, spoke to him but said she didn’t find anything strange about his behaviour.

Mr Telfer met a friend, Michael Henderson, in Whitehaven that afternoon. There Mr Telfer bought two bottles of cider and asked his friend to drive him to nearby Design Scaffolding.

Mr Henderson said: “He said he was going down there to sit on a reclining chair. There was something amiss but I thought it was just Matthew. Nothing concerned me.”

A worker found Mr Telfer at about 4pm.

The cause of death was hanging, a post mortem revealed. He also had alcohol in his system.

Following tributes at the inquest, coroner Simon Ward said: “The impression you have given me of Matthew is that when he was his normal self he was good fun, a good friend and a good partner.”

He said: “It’s evident to me that Matthew suffered flashbacks due to being abused when he was a lot younger and over the years he had suffered with his mental health.”

Mr Ward said Mr Telfer’s previous attempts to kill himself “may have been a cry for help and others may have been significant”.

He said Mr Telfer sought help and he was “open and honest” with his loved ones and services such as his GP, Crisis and Unity.

Following Mr Telfer’s death, reviews were carried out by Unity and Crisis.

A Unity representative highlighted “a lack of communication between services”.

In order to strengthen communication links between services, for the management of complex mental health cases, Unity and Crisis are working together to review and improve already established local protocol.

Mr Ward said: “It is clear any shortcomings are being addressed. It is unknown if further intervention would have made any real difference.”

Following the inquest a spokesperson for Cumbria Partnership NHS Foundation Trust for the Crisis team, said: “The trust would like to extend our sincere condolences to Mr Telfer’s family at this very difficult time. We have taken his death extremely seriously.

“We have listened to what the coroner has to say and will be looking at this again to ensure that all possible lessons are learned, we remain committed to providing the highest possible patient care.”