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An"inadequate" mental health system which sent a Liverpool man home from hospital hours before he set fire to himself has improved since his death, an inquest heard.

Dad-of-three Graham Wright, 37, died on November 17, 2011, after a fire at his flat in Worcester Drive, Clubmoor.

A mental health assessment in the early hours of that morning had decided he was safe to return home.

Coroner Andre Rebello recorded a narrative verdict when the inquest into his death concluded.

He said that the system experienced by Mr Wright was “inadequate” but the inquest heard it had since been improved.

Mr Wright, who suffered from a borderline personality disorder, was detained under the Mental Health Act by police officers on November 16, 2011, after threatening to set fire to himself.

Officers took him to a “designated place of safety” at the Royal Liverpool University Hospital at about 4.30pm but Mr Wright had to wait until about 1am to be assessed.

The inquest heard Careline, which provides approved mental health practitioners, had only one practitioner on duty out of hours.

While waiting with police Mr Wright told them he wanted to kill himself on a number of occasions and had to be restrained in handcuffs at one point.

PC Paul Molyneux, who came on shift at about 11pm, said he heard Mr Wright tell mental health practitioner Emad Lilo “I'm going to kill myself, I've been planning this all week and these b******* stopped me”.

He was allowed to return home at about 2am after the assessment, which was carried out by Mr Lilo and two doctors.

Mr Rebello said it was “unclear” whether the result of the assessment would have been different had Mr Wright been assessed sooner or had the team assessing him asked for information directly from the police officers.

Mr Wright failed to answer his door to mental health staff later that morning.

Emergency services were called to the fire at his flat at about 1.30pm and he was taken to the Royal before being transferred to Whiston, where he was pronounced dead.

A post mortem found he died of severe burns.

The inquest heard since Mr Wright’s death the system had been changed so there was greater resilience for availability of mental health practitioners, more flexibility for police to leave mentally disordered people with support workers and assessments were able to be carried out “in a timely manner” if there was a delay in a mental health practitioner being available.