'No human being should have to go through what we've been through'
For Tony Williamson, a round of golf was one of life's great pleasures. A fit, healthy and active 62 year-old, he loved nothing more than letting off steam over 18 holes with his pals.
But one Friday afternoon, Tony, came home early from a game. He told his wife Jackie he felt 'off-colour.' These were the first signs of a condition that would leave the cherished dad-of-two and grandad in 'unbearable' daily pain.
It was also the start of a traumatic and devastating series of events which would see Tony lose his life. Just a year later he would vanish from the family home in Timperley sparking a huge and well-publicised search operation.
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For three months his family were left in a 'living nightmare' – on tenterhooks every single day waiting for news. In March last year, his body was discovered in a stretch of the River Mersey in Warrington. A coroner has ruled he took his own life 'whilst experiencing hopelessness whilst under investigation and treatment for pelvic pain.'
The inquest, which concluded last month, heard there was a 'disconnect' between those investigating Tony's physical health problem and those dealing with the related decline in his mental health.
The coroner has now written to the Health Secretary to raise concerns. Ultimately his family feel that after giving so much to the NHS, it 'failed one of its own.' And they want to see his story become a catalyst for change.
Tony, a big Manchester City fan from Wythenshawe, met wife Jackie, now 62 and from Stretford, when they were teenagers and they were together for more than 40 years.
They settled in Timperley and had two sons - Simon, now 34, and Sam, now 33. After graduating from Salford University, he began working for the NHS aged 21.
For 37 years he worked as a podiatrist, at Wythenshawe Hospital, and in the local community. He had taken early retirement to spend more time with his wife but was still working part-time at his own practice which he had had for over 30 years.
"He had a good sense of humour", Jackie said. "He was a bit of a character and used to wind people up. He was a counsellor half the time, especially when you'd had a bad day at work. But he would always turn things around."
"He was a very caring person," she continued. "He loved his patients and was very helpful. He'll have helped so many people over the years. He always went above and beyond. They were more like friends than patients, even the NHS ones."
Tony became a grandad to Simon's son and Sam's daughter, now both aged three, and after his semi-retirement was playing golf three times a week. He was even teaching Jackie how to play.
But it was after his aborted game in November 2022 that things started to go 'downhill.' "He had never been ill in his life", Jackie said. "Obviously he'd had the old cold, but that was it.
"But he said he didn't feel well, then he started with the pains".
"He was having problems with his prostate and the pains were all underneath," she continued. "He couldn't wee, he couldn't empty his bowels."
He went to the doctors and was referred to urology but was told he could have to wait until March the following year for an appointment. "He couldn't wait that long," Jackie said. "The pain was continuous."
He paid for an appointment at a private hospital where a doctor told him it was likely 'chronic prostatitis' - the medical term for an inflamed prostate.
Jackie said they paid 'numerous visits' to the GP before he saw a specialist on the NHS in May 2023. "It felt like no one was really listening to us, and that's been the problem all along," she said.
Tony 'wasn't soft by any means' and had 'quite a high pain threshold' his family say. But the pain he was experiencing was so bad at times he 'couldn't do anything else.' He would resort to just lying on the sofa in agony, they said.
"When he lay down the pain was easier but when he stood up it was horrendous," Jackie said. "He would cry. He could hardly walk. As soon as went out walking, that was it. You felt horrendous and helpless."
"He was being told to take paracetamol and ibuprofen," Simon said. "That does nothing for me when I have toothache, never mind the pain my dad was in."
"I think they thought the pain was in his head", Sam added. As Tony's pain continued, his mental health began to decline. He began experiencing suicidal thoughts.
He had two short stints as an inpatient at local mental health wards, in September and November 2023, after threatening to harm himself. But his physical problems meant mental health wards were, according to his family, 'just the wrong environment' for him, and on both occasions he wanted to be at home.
His family say his actions were a 'cry for help.'
"He just wanted help, he was pleading for help", Simon said, adding that he wanted to be admitted to hospital as an inpatient for his physical problems instead.
After being discharged from the mental health units, he was under the care of the Trafford Home Based Treatment Team (HBTT). However the coroner said there was an 'absence of a collaborative and coordinated approach between medical and mental health teams which contributed to a feeling of hopelessness in Mr Williamson.'
"We were being kicked from one side, to the other every time", Simon said. "It was like being in a pinball at times. There was no collaborative approach. It was just 'we've done our bit.'
"But nothing was being joined together. We had to tell the mental health team what was going at times.
"They kept sending different people. You'd tell them everything and the next day he'd have to tell them again. He said he felt he was continually repeating himself."
"Tony knew he was being messed about," Jackie added. "He kept saying 'the old Tony's died' and 'I'm not going to get out of this.' I think he knew he wasn't going to get anywhere. He lost weight. He used to shake as well."
"He was never the same," Simon said. "He was a shell of his former self. He would never have did what he did had it not been for the pain he was in. He had no quality of life. All he wanted was a better quality of life."
He had been referred to a specialist pain clinic but despite new medication being tried, his agony continued. Problems urinating saw him have a catheter fitted at A+E in early December 2023.
At the same time, his family were so worried about his mental health they had resorted to keeping him locked in the house. However on December 19, whilst Jackie attended a medical appointment of her own, he used a key he had hidden in his wallet in order to leave.
The family's missing from home report was treated as a Grade I incident, the highest category and where there is considered to be a threat to life. A police helicopter joined officers, family and friends searching the local area for him. He was captured on CCTV footage walking down Greenway towards Park Road in Timperley at 11.12am.
But despite extensive enquiries and physical searches, he could not be found and he wasn't pinpointed on any further footage. There were reports he had been seen elsewhere in the country, with GMP officers at one point travelling to Nottingham to carry out enquiries, but they turned out to be incorrect.
A month on from his disappearance his family made a pubic appeal for him to come home as they urged people to come forward with information.
"It was a living nightmare. I can't even begin to describe it. You just wake up every day hoping they'll find him," Simon said. "You're just praying he'll be alive but at the same time fearing the worst. And it was a strange emotion when he was found because it's relief you've heard something, but absolute heartbreak that he's gone at the same time."
His body was discovered on Sunday, March, 17 last year in the stretch of the River Mersey near Warrington Rowing Club, off Howley Lane in the Cheshire town. Toxicologal analysis found there were no drugs, other than medication at theraputic levels, in his system and a 'very low level' of alcohol. Pathologist Professor Richard Byers gave his cause of death as dry drowning.
Police concluded he had been in the water for 'some time' and that there were no suspicious circumstances. Following the inquest at Stockport Coroner's Court, which was held last month, Assistant Coroner Adrian Farrow, said it was not possible to say exactly where or when he had entered the water, but that he believed he had entered the Bridgewater Canal or 'a brook close by' and that he did so 'deliberately.'
He recorded a narrative conclusion that Tony, who was 63 at the time of his death', 'took his own life whilst experiencing hopelessness whilst under investigation and treatment for pelvic pain.'
In a Prevention of Future Deaths, report which has now been made public, he said there is 'no formal framework either locally or nationally to facilitate inter-specialty communication, particularly in complex and dynamic cases.'
The impact it's had on all three of us is unbelievable", Simon said.
"Even to this day we are in disbelief. We have got to live with this for the rest of our lives.
"The trauma we've been through. No human being should have to go through what we've been through. But we can take comfort if this doesn't happen to another family who may be going through a similar situation."
A spokesperson for Manchester University NHS Foundation Trust, who provided Tony's urology care, said: “We wish to extend our condolences and deepest sympathies to Tony’s family at this incredibly difficult time.
"We are committed to providing the best care possible for our patients and we will be reviewing the Coroner’s findings carefully, to ensure any further learning for the Trust is addressed and applied to our constant work to improve our patients’ safety, quality of care, and experience.”
The Greater Manchester Mental Health Trust (GMMH) and the Department for Health and Social Care (DHSC) have been approached for comment.