Suffolk’s senior coroner has said that a man may not have taken his own life, if he had received support from mental health services during the weekend leading up to his death.

Nigel Parsley, senior coroner for Suffolk, has written to the Secretary of State regarding the death of Nigel Hammond.

Mr Hammond died in Addenbrookes Hospital on March 14, three days after falling at his Suffolk home.

In a Prevention of Future Deaths Report, Mr Parsley explained that Mr Hammond had struggled with his mental health for a “protracted period”, having been admitted to a mental health unit in 2018, where he remained for three months.

Mr Hammond found his admission to the unit “very traumatic”, Mr Parsley wrote, and was described as “terrified” at the thought of ever being admitted again.

Following his discharge, Mr Hammond’s family, carers and the mental health home treatment team worked together to provide “exemplary” care, Mr Parsley wrote.

However, his mental health began to suffer in March of this year. On Saturday, March 9, he was prevented by his family from ending his life.

That evening, his family contacted the Authorised Mental Health Professional (AMHP) from the Suffolk Emergency Duty Service Team.

An AMHP is a clinician approved to coordinate the assessment and admission to hospital of people requiring admission under the Mental Health Act provisions.

During Mr Hammond’s inquest, it was heard that the AMHP agreed with his family that treating him at home would be in his best interest.

The AMHP felt that Mr Hammond was in need of “immediate support”, which should be available from the emergency Crisis Resolution and Home Treatment Team within a 4-hour target.

However, the court was told that an AMHP is not permitted to make direct referrals to the team. Normal procedure would be for referrals to be made via the GP surgery or by a primary care mental health nurse – neither of which would be available until 8am on Monday, March 11.

Mr Hammond suffered the fall which led to his death at 6.25am that morning.

An inquest into his death concluded on Tuesday, with Mr Parsley recording a conclusion of “suicide, whilst the balance of [Mr Hammond’s] mind was disturbed”.

Now, Mr Parsley has written to the Secretary of State, the Norfolk and Suffolk NHS Foundation Trust and Suffolk County Council with concerns regarding Mr Hammond’s care.

Had the AHMP been able to directly refer Mr Hammond to the Crisis Resolution team on Saturday, March 9, he would have been seen and supported by mental health professionals.

They would have been able to provide additional support, advice and potentially treatment to Mr Hammond, “in all likelihood preventing his death,” Mr Parsley wrote.

The government, county council and NSFT are required to respond to Mr Parsley by December 4.