A young father hanged himself just 24 hours after he was refused a bed in a psychiatric unit - despite fears he would take his own life.
Kieran Hubbard, 20, who had recently broken up with his girlfriend, was referred to a senior psychiatrist after he was found at the top of a motorway bridge.
But although the consultant recommended Kieran be admitted as an inpatient due to concerns for his safety, healthcare professionals overruled her and instead suggested he be seen at home.
The following day Kieran drove to a building site where he had been working in Ancoats, Manchester and hanged himself inside a former mill he was helping renovate.
In the minutes before his death he left a series of notes reading ''love and goodbye'' and sent a heartbreaking Facebook message to his father Kevin saying his mental condition had left him “paralysed with an overwhelming sense of fear.”
In his message, Kieran said: “It sounds ridiculous to anyone who doesn’t suffer with mental health but I wouldn’t wish it on anyone.
"It completely takes over you mentally and physically. It’s like a complete state of trauma and you can’t speak, feel an urge to cry, too scared to be with anyone but not wanting to be alone, feeling lost about what to do or how to do it.
“Feeling in a daze and simultaneously being unaware but also aware of everything around you.
"You just want to stay in bed and escape but then you fear what other people are thinking if you don’t act normal, this continues until either you just give up through exhaustion or collapse and fall asleep.”
Mr Hubbard, 44, a director of the construction company Kieran was working for raced to the scene after getting the message but by the time he arrived his son was already dead.
At an inquest he condemned local mental health services for letting his son down as a coroner said he would be filing a report to NHS officials calling for better provisions for patients.
Mr Hubbard from Terrington St Clement, near Kings Lynn said: ''We were let down by the system.
"The whole system let him down. He wasn’t hiding his illness, he wanted help and they let him down. He was passed from pillar to post.”
Kieran, who was living in temporary accommodation in Salford, had just become a father but in the lead-up to his death in February last year he had split up with the child's mother and his mental condition deteriorated.
He was later found on a motorway bridge and referred to the Greater Manchester Mental Health Team for a psychiatric assessment.
Mr Hubbard told the Manchester hearing: ''He knew we loved him but he couldn’t get the suicidal thoughts out of his head. It was becoming more and more frequent but he said but he said he had no intention of doing it.
“The very last time I spoke to him properly was at 10am on February 8. He was very calm and said he was fine.
"I offered to go pick him up and bring him to Norfolk because I didn’t want him on his own. He was adamant he was fine and wasn’t at risk, in a good place.
“He was going to go see the baby that afternoon he seemed quite happy he seemed fine, he had new medication, so he was going to start that.
“But then one of his friends phoned me up and said you better get in touch with Kieran he has posted something.
“Straight away as soon as he said it I panicked. I immediately packed up work and tried ringing him no end of times and he wouldn’t answer.
“When I got in the car and set off, he did answer and he just said ‘I love you’.
“I phoned the Salford Mental Health unit and told them to get to him but they advised me to phone 999.
''I had numerous calls from the police on the way asking me his car registration and I was trying to tell them the site address.
"I got there and went straight round the back and saw Kieran’s car.''
Dr Suraya Khan, consultant psychiatrist said Kieran was referred to her on February 4 and added: ''I was concerned about him being in acute mental health crisis and I concluded he was suffering from a recurrent depressive disorder.
"At that point he was suffering a current severe depressive episode and it was marked by recurrent suicidal thoughts.
“His depression had all the core features – loss of interest and enjoyment, pervasive low mood and lack of energy.
"He also had poor sleep and poor concentration, feelings of helplessness and worthlessness.
"He said thoughts of his newly born baby were a protective factor and I suggested inpatient treatment and I identified a need for the bed.
''I spoke to a duty worker and explained that these are my findings but when I requested the bed there was a member of the Salford management team present who advised me that he wouldn’t be entitled to a bed in Salford because although he was temporarily residing in Salford, he was registered with a GP in Bury.
“She advised that the duty worker contact Bury bed management but they had replied that Bury bed management said no admission indicated.
"I got the impression that Kieran didn’t meet the threshold for their admission. It was an unusual refusal which I have never experienced having assessed a patient’s clear diagnosis.''
Sharon Morrison a mental health nurse who investigated the tragedy said: ''Pennine Care told me they had left the referral open and were waiting for more information.
''My understanding was that the team had talked about whether or not Kieran needed a bed and together they came to the conclusion that he would be OK for him to be at home because he now understood what a home-based treatment team was about.''
''Dr Khan's views were not sought not was she updated the following day. Had it been pursued at the time then it is possible there might have been information ascertained which may or may not resulted in the presence of a bed.
“I’m going to make a prevention of future deaths report to Greater Manchester Mental Health Team it will encompass record keeping, but also in the sense of referrals to other trusts that appropriate records are kept at all times.
"It seems to me in this case there was an opportunity of providing information that whilst it ultimately might not have resulted in a bed - it could have done.''
If you need to speak to someone, Samaritans are available 24/7 by calling 116 123 or by emailing jo@samaritans.org
