THE wife of a gambler who hanged himself in their disabled son's room, died four week later from a fatal cocktail of alcohol and tablets, a double inquest has heard.

Susan Connell, 54, of Egham Green, Idle, was found dead on March 5 this year after her son's worried social worker alerted police.

The inquest yesterday heard how Mrs Connell had been struggling to cope after her husband, Stephen Connell, also 54, took his life on January 30 - the day their son had been due home from respite.

Coroner Martin Fleming concluded while Mr Connell's death had been suicide, Mrs Connell might not have intended to do herself harm and may have misjudged self-medication for chronic back pain.

The court heard how Mrs Connell's daughter, Naomi Wedderburn, was so concerned about her mother she had called Lynfield Mount Hospital. Mrs Connell was assessed by Bradford District Care Trust and put under the care of its Intensive Home Treatment Team.

Mr Fleming said there had been were gaps in her care though, including a breakdown in communication.

The court had heard how social worker Matthew Scott, who works at the Airedale Centre for Mental Health, told Mrs Connell in a 20-minute phone assessment the better option for help would be the Citizens Advice Bureau.

Mr Scott admitted he had not read her notes in detail and had only been looking for words relating to suicide. He did not feel she was at immediate risk.

He thought he was assessing a new referral, oblivious that she was already on the Trust's caseload, and he had not seen a message left by Mrs Connell saying she was struggling. He felt her main problem was sorting out her husband's debts which was not in the mental health remit, he said.

But it was in her notes that her daughter and GP had significant concerns about her mental health. The police had also been involved on occasions and had taken her to A&E for a well-being check.

"Don't you think this was a worrying background?" Mr Fleming asked.

"In 20 minutes you made a risk assessment that it was in her best interest she goes to the Citizens Advice Bureau," he said.

Mr Scott told the inquest: "I read the notes so quickly I had not gained the correct context."

The court was told that now, following a serious incident investigation at the Trust, discharges are made by a team decision.

Crisis cards with phone numbers are given to all patients to get help from the right team and all referrals are treated as being admitted under the Trust's care.

Miss Wedderburn, who felt her mother had not got the right care, said: "It's just a list of recommendations to possibly save other people in the future, but not my mum."