A "kind and quirky" 29-year-old from Woodbridge died after being involved in a crash while in the road, an inquest heard.
Owen Gardner died in the early hours of Bank Holiday Monday, May 8 last year after being struck by a car in the middle of Melton Hill.
Mr Gardner, who has been described by his family as "generous, kind and quirky with an infectious smile and laugh" had been having drinks the night he died.
During the hearing, it was heard that he was struck while lying in the middle of the road.
Suffolk Coroners' Court in Ipswich heard how Mr Gardner had a previous history of walking out in front of moving vehicles when intoxicated, having done so in September 2013 when he was struck by a lorry.
He suffered multiple injuries including brain damage, which affected his decision making and memory so much so that when he was sober, he wouldn't remember being hit by vehicles.
The Red Lion in Woodbridge, where Mr Gardner had been drinking prior to his death (Image: Ollie Harrop)
At the inquest, senior coroner for Suffolk Nigel Parsley read witness statements taken after the crash and heard evidence from Suffolk police figures and a Norfolk and Suffolk NHS Foundation Trust (NSFT) mental health professional.
Mr Gardner, a former student at Farlingaye High School, had been diagnosed with depression and was known to self-harm.
His care coordinator that had been assigned to him, Sarah Gifford, discharged him three days before his death.
This, however, was not discussed with Mr Gardner's parents, even though he had given permission for information regarding treatment and appointments to be passed to his mother, Maura.
When she asked her son what the next steps were for him, he replied "I don't know" due to his short memory.
On the night of Mr Gardner's death, he had gone to the Red Lion in Woodbridge and was seen by friends who were there.
One of his friends he had known since 2017 said she saw Mr Gardner in the garden seeming a "little quiet and off", but this was common for him so she didn't think much of it.
Staff at the Red Lion knew Mr Gardner and limited how much he could drink.
Just after midnight, Mr Gardner made his way up Melton Hill and was lying down in the middle of the road with cars parked either side when a 17-year-old, who had only passed his test in October 2022 and who was driving on his way to see a friend, struck Mr Gardner.
In an interview with police investigator Cheryl Huggins, he said that the road was very quiet and it was only at a distance of one or two car lengths did he see something.
Due to Mr Gardner wearing dark clothes that night, he blended in with the road - with the teenager mistaking him for bin bags.
PC Alex Vinter, forensic collision investigator, said that with full beam it would have taken the young driver just under five seconds to react, and with dipped beams he would have less than a second to respond to seeing Mr Gardner in the road.
He also said that there was no mechanical or environmental conditions that could have contributed, the driver was not under the influence and there was nothing to suspect he was distracted while driving.
The car, a grey Seat Ibiza, was only damaged on the underside of the car after the impact, with the airbags being deployed - adding further to the panic and shock and explained why the car was further away from the incident site.
A voluntary first responder, Colin Davis, came across the collision at 12.20am after being flagged down by the driver, who was shouting: "Oh god, what have I done".
Mr Davis grabbed his life-saving equipment from his car, and he and another bystander started performing CPR on Mr Gardner before the ambulance service arrived.
After 45 minutes of CPR, Mr Gardner was declared dead at 1.05am.
Mr Parsley gave a short form conclusion of road traffic collision.
He said that it would not have been a suicide due to Mr Gardner having previous history of doing this when drunk, and not remembering it.
Mr Parsley added that he would write a prevention of future deaths order as "there is no obvious system in place that alerts family members that have been given permission to be informed when an appointment has changed, especially when someone has a poor memory".
He added: "A system needs to be in place for loved ones to be alerted when an appointment or treatment is changed, particularly for a patient with short memory.
"I will be raising this within the next 10 days."
A spokesperson for Norfolk and Suffolk NHS Foundation Trust, said: “We would like to pass on our deepest condolences to Owen’s family and friends at this sad time.
"We are committed to listening to and responding to any concerns raised by Owen’s family or the coroner, as we continue to work with and listen to families, carers, service users and partners to provide safer, kinder and better care."
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