"Multiple failures" by police, paramedics and mental health services contributed to a man's suicide, an inquest jury has found.
Adam Stanmore, a 37-year-old from Oxford, was found dead on 13 June 2019.
He had been living with self-reported depression and also had type 1 diabetes.
Mr Stanmore's death was recorded as suicide by hanging and/or hypoglycemia.
But Oxford Oxfordshire Coroner's Office heard that he did not receive appropriate psychiatric evaluations and was not properly dealt with by authorities in the lead up to his death.
Assistant coroner Sonia Hayes said there were multiple failures by agencies prior to Mr Stanmore’s death.
On 23 April 2019 Mr Stanmore contacted his GP to report paranoid thoughts and voices telling him to kill himself.
He was referred to the Oxford Health Foundation Trust and seen on the same day.
Following the assessment, Mr Stanmore was given a post-it note with the telephone number of MIND and told to go back to his GP for antidepressant treatment.
On the morning of 18 May 2019, Mr Stanmore left his mother’s house leaving a note stating that he “had enough”.
In the early afternoon, he obtained a knife from a neighbour who called Thames Valley Police out of concern for his welfare.
Mr Stanmore was found by Thames Valley Police sitting on his own on a fence.
He told them “I want to kill myself.” Armed Response Officers then arrived and approached Mr Stanmore.
They took hold of Mr Stanmore and saw there was a knife in his waistbelt.
As an officer was removing it, Mr Stanmore put his hand on it. The police then discharged Taser on three occasions and used force to restrain Adam and remove the knife from him. The inquest found the use of the Taser was reasonable.
He remained prone on the ground with leg restraints until the arrival of the police van.
Mr Stanmore was then taken to Abingdon Police station.
On arrival, he was barely conscious and his blood sugar levels were critically low.
He again told police that he wanted to kill himself. South Central Ambulance Service was called to convey Adam to the hospital for physical and mental health assessment and treatment.
No further action was taken in relation to his arrest. The evidence of the paramedics was that they were not made aware that Mr Stanmore had told police officers that he wanted to kill himself.
During the journey in the ambulance, Mr Stanmore told the paramedics that he had overdosed on insulin to try and kill himself.
This information was recorded. It later was deleted and only came to light during the inquest.
Mr Stanmore was allowed to leave the ambulance before it reached the hospital.
No mental health capacity assessment was carried out and Mr Stanmore refused any additional treatment or checks of his blood sugar levels.
Paramedics then provided information to police and central control that Mr Stanmore was fully recovered.
Police located Mr a few hours after he had left the ambulance but were reassured by a lack of markers in their own system and by the information provided by the paramedics.
Oxford Mental Health street triage decided that they would not perform a face to face mental health assessment on the basis of the information from police officers that Mr Stanmore seemed fine.
He was last captured on CCTV at around midnight after police had left him. Mr Stanmore's body was found weeks later on 13 June.
Speaking after the inquest concluded on 30 July, Laura Klee, Mr Stanmore's ex-partner, said: "We have been truly shocked and saddened by the blatant disregard shown towards Adam in his final hours by those who could have saved him, in particular the ambulance crew.
“We can only conclude that a great number of people involved in Adam’s care that day simply did not care.
"We truly believe that there was no part of Adam that wanted to end his own life that day, but due the psychosis he was experiencing, felt he had no choice.
Ms Klee added: "As a family, this has never been about blame or finger pointing, but about finding answers to something that has been incredibly difficult to process. We hope mostly that learning will be done and from this and other’s lives may well be saved."
Selen Cavcav, senior caseworker at INQUEST, who worked with Bhatt Murphy solicitors on the case, said: “It is utterly shameful that Adam was left to die in these circumstances and basic standards of care necessary to protect those in distress fell by the wayside as they did.
“This inquest highlighted yet again systemic issues around how the agencies respond to people with mental ill health.”
OHNHST and SCAS apologised to Mr Stanmmore’s family “for the opportunities that were missed during his care”. Both organisations have launched investigations and changes have been made to “ensure that our systems and practice remain safe for our patients and for our staff in the future.”
Thames Valley Police said it also sent condolences to Mr Stanmore’s family.
A spokesperson for the force said: “We will of course review these findings and recommendations from HM coroner and take any necessary action.”
Mountain Healthcare has been contacted for comment.
If you or anyone you know is experiencing mental health problems, The Samaritans can be contacted free on 116 113 or by visiting samaritans.org
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