Pawel Bukowski, 48, was found dead at his home in Norfolk in April last year after Turkish dentists removed his teeth but sent him home without new implants.
An inquest has now found that the NHS “missed” opportunities to prevent the forklift driver’s death, which a coroner ruled was suicide.
Mr Bukowski travelled to the country in January 2025 for the treatment after suffering from periodontal disease, a chronic inflammatory condition.
Mr Bukowsi was told by dentists that once his teeth were removed, he would be given temporary dentures while he waited for a second permanent implant procedure several months later.
Daria Bukowska, his widow, told the inquest at Norfolk coroner’s court: “Unfortunately, after removing all of his teeth, the clinic told him they could not proceed further.
“They sent him home without any teeth and told him to return in six months. This was emotionally devastating for him.”
The inquest heard mental health workers concluded he was “hopeless with a strong suicidal ideation” and there were concerns for his “safety and wellbeing”.
However, they chose not to admit him to psychiatric care because of “sufficient protective factors” and sent him home to his family, who were given medication for him and advice on keeping him safe.
On April 26, his “heavy” drinking prevented a nurse from prescribing him further medication.
On April 28, a psychiatrist was due to visit him at home at 10am but staff sickness meant he was not visited until shortly before 1pm, when he was found dead.
Johanna Thompson, the area coroner, recorded his cause of death as suicide and said there was “evidence of Pawel’s intent to end his life in the messages and notes he left”.
The Norfolk and Suffolk NHS Foundation Trust investigated itself following his death and found the decision not to admit him on April 24 was a “missed opportunity”, the coroner said.
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Source: The Telegraph, 13 April 2026