A mental health trust has admitted it ‘let down’ an Andover man who was found dead in his home after not having been seen for three weeks.

Anthony Paul Garnett was found at his Barley Road home on August 24, 2020, following concerns being raised by neighbour. Winchester Coroners’ Court heard how his annual physical check-up with Southern Health, due to his clozapine prescription was missed due to a “systems error”, and that there had been “a lack of home visits” to his address.

Louise Earl, from Southern Health, said that changes had been made following the 62-year-old’s death, including more regular visits, safeguarding overview meetings and a review of caseloads by managers.

A verdict of accidental death was given.

The inquest heard that Mr Garnett had been diagnosed with schizophrenia in 1988, but that he had always been “very compliant” with his medication for the condition, clozapine, and was “very conscious of what he should and shouldn’t do.”

His sister, Jane Canning, said that during her twice-yearly visits from her home in New York he had suffered “five years of worsening OCD” and had panic attacks in 2017 and 2018, but had improved in the following years.

She said that her brother would have found Covid “incredibly difficult to deal with”, saying: “It’s confusing for those able to fully deal with life but he was closeted and loved to watch the news so he was well-informed. The news cycle at the start of the pandemic was very worrying so it would have been even more confusing for him.”

At the time, Mr Garnett was living in a flat provided by VIVID housing, where he became friends with his neighbour Corrine Whitlock. She supported him by providing shopping and food, and had become concerned when he didn’t answer his door.

In a statement, she said that she called the emergency services and was told that ‘it wasn’t their issue’, and that eventually paramedics visited, where Mr Garnett was found cold and with his toilet blocked upstairs when a window was broken to gain access.

Ms Whitlock provided him with further support, but suffered a similar issue gaining the help of the emergency services in August when she stopped seeing him. Eventually, police arrived and broke down the door, where Mr Garnett was found deceased in his flat.

Corrine told the inquest: “I’m so upset with everyone. He wasn’t a neighbour, he was a friend. I asked for help for Tony on so many occasions but he never saw a support worker.”

A post-mortem was subsequently held at Winchester Hospital, which was limited by the advanced state of decomposition, with the coroner, Christopher Wilkinson, saying that it was “likely” he had died in the first week of August before being discovered three weeks later.

Toxicology testing found that there was a level of clozapine within a range previously associated with fatality in his liver, and in the absence of other evidence, clozapine toxicity was given as the cause of death.

The coroner questioned Louise Earl on this matter, as his clozapine prescription meant that he should have been given a yearly physical, which was due in March 2020.

She said that a review had “identified there were some gaps in the care and treatment of Mr Garnett”, but added that Southern Health staff were “extremely open about how they let him down” and were “distressed” after hearing of his death, with the missed physical attributed to “systems error” as staff changed. She said there were now “robust systems” to ensure physical checks went ahead.

Ms Earl said that there had been safeguarding concerns relating to his accommodation, and that the causes had been documented but there was “no documentation on how to monitor this”. She also said there had been a lack of home visits.

She said: “There have been less visits over the past few years, and an increased reliance on people with complex needs coming into the clinic. Regular home visits are now in place, and there are regular safeguarding overview meetings with all the staff from Winchester and Andover to share learning.”

The coroner said that despite the lack of visits, there was “nothing to positively indicate he had issues with medication use,” but said there should be an emphasis on supporting those with mental health in the pandemic.

He said: “Covid has put pressures on the NHS, but equally a lot of individuals who have been marooned without contact.

“We do need to ensure as part of the overall recovery that the gaps are identified and plugged.”

Giving his verdict, the coroner said that there was “no indication” he had attempted to take his own life, or was suffering with depression, with his sister suggesting that he may have been eating and drinking little due to the warm weather of that summer.

The coroner concurred, saying: “It is very highly likely he wasn’t eating or drinking properly, and there is a very real possibility they may have contributed to death if so.”

He added that it was out of character for Mr Garnett to self-medicate, but that it “was not beyond the pale.”

He said that a verdict of accidental death fitted the facts on the balance of probability.

Paying tribute to her brother, a former Harrods worker, Ms Canning said that he was “a very gentle person, who loved his current affairs and was incredibly well informed about what was going on in the world.

“It was very sad he met the end he did.”