A devastated mother has told how she believes her son was let down by the health service after he hanged himself shortly after being seen at hospital several times in a matter of days.
Delivery driver Kyle Dixon (29) of Hallam Road, Nelson, was found dead by a member of the public in Plumbe Street, Burnley, on May 23rd last year.
An inquest at Burnley Coroner's Court heard from his heartbroken mother Ruth Bancroft and his sister Kara Dixon who said he had been let down by East Lancashire Hospitals NHS Trust.
Coroner Mr Richard Taylor heard evidence from the family and from Dr Georgina Robertson, from the Trust, who said Kyle had been seen at the Royal Blackburn Hospital three times two days before his death but released every time.
Mr Dixon had also presented himself at 1-30pm at Burnley Police Station where he suffered a "pseudo-seizure", thought to have been brought on by stress and mental health issues.
Police officers sent Mr Dixon to hospital by ambulance where he was again assessed by the emergency department and mental health team, but assured them he was not suicidal.
Dr Robertson told the inquest that hospitals had to follow "extremely strict criteria to section somebody" and that staff did not feel it was appropriate in Mr Dixon's case on any of the occasions he was seen at the hospital. She added that hospitals could only detain people if staff felt the patient didn't have the capacity to make a decision or were physically unwell enough to.
On his previous visits to the hospial, Mr Dixon had presented with chest pains but observations had come back normal. On a later visit his behaviour was seen to be "erratic" but with no threats of self-harm or suicidal behaviour.
Mr Dixon had also complained of having flashbacks, being disorientated and was acting in a paranoid manner. On a third visit he claimed he had been falsely accused of crimes and was having voices in his head telling him to be strong.
His devastated mother Mrs Bancroft told the inquest: "Kyle never believed he was ill. I fought all my life to get him diagnosed correctly but it always went haywire. I feel that the mental health team at the hospital would have known about his problems if they had accessed his GP records.
"I worry it's going to happen again to someone else. It's very sad."
Sister Kara Dixon questioned why concerns were not raised by hospital staff after her brother at presented himself at the hospital three times in one day.
She said: "I feel he's been completely failed by the Trust. Three attendances on the same day would register in anyone's mind a concern that something wasn't right."
Recording a conclusion of suicide, the coroner said: "Kyle Dixon was a young man whohad presented himself at hospital with different sorts of issues. His mental health was assessed but he wouldn't accept he had issues.
"Whilst I fully accept the family's concerns about raising alarm bells, we have to balance that with the powers that hospitals have to detain people. The Trust could only signpost him to a GP. His GP records state that he last visited three years before his death and only brief details would be available to the hospital staff."