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A man who took his own life might have been saved if mental health crisis referrals were improved, a coroner said.

Nigel Hammond died in Addenbrooke's Hospital, Cambridge, on 14 March, three days after falling at his Suffolk home.

In a Prevention of Future Deaths Report, external, senior coroner for Suffolk Nigel Parsley said a mental health support team could have got him help sooner, had they not needed to go through a GP first.

In his report, following an inquest this week, Mr Parsley said Mr Hammond had become "seriously mentally unwell" in 2018 and was admitted to a mental health unit for three months.

He had found the admission very traumatic and was "terrified" of the thought of being admitted again. Instead he continued to receive "exemplary" mental health care at home.

On 8 March 2024, his mental health declined again and he was taken to his GP.

The following day he tried to end his own life but was prevented by family intervention, the report said.

His family immediately contacted the on-duty authorised mental health professional (AMHP) from the Suffolk County Council-managed emergency duty service team.

Mr Parsley said he was "concerned" the AMHP had not been able to directly refer Mr Hammond to the crisis team, which would have provided additional support, advice and potentially additional treatment, "in all likelihood preventing his death".

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Source: BBC News, 11 October 2024

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