A 48-year-old man suffering anxiety and depression was found dead in a river.
Scaffolder Stephen Whelan's body was recovered from the Cut-Off Channel at Fordham Bridge, near Downham Market, by police divers on Friday, April 7 last year.
An inquest into his death at King's Lynn coroner's court heard his mental health began to deteriorate in 2016. The court heard Mr Whelan suffered tinnitus, which he found increasingly hard to bear.
In September 2016, he attempted to take his own life. In December 2016, his GP Dr Michelle Nowers said he was depressed and having suicidal thoughts. On March 10, 2017, Mr Whelan was referred to the crisis resolution and home treatment team after he again attempted suicide. On March 23, he was discharged back to the care of his GP. Police Sgt Scott Hemeter, who was present when his body was recovered, said items found with it indicated suicide.
The Norfolk and Suffolk Mental Health Trust, which had discharged Mr Whelan from its care before his death, classed it as a 'serious incident' requiring investigation. Its deputy services manager Stephanie Payne was asked by Mr Whelan's family how serious someone's condition would need to be before they were admitted to the Fermoy Unit. Mrs Payne said decisions were made on a case-by-case basis.
Mr Whelan's mother Marion said: 'Can you tell me why my son was begging for help and didn't get it. It's difficult to take my son's death. He got no support from mental health, from the crisis team, they should be ashamed of themselves.'
She said when her son rang the mental health team, he was told to call the Samaritans.
Mrs Payne said the investigating panel had found notes entered onto its system by a clinician had been lost and more 'robust' evidence needed to be noted in records. But she added: 'The panel concluded these shortcomings would not have impacted on the eventual outcome.'
Assistant coroner Johanna Thompson concluded his death was suicide. She said: 'In view of the circumstances, I'm satisfied it was a deliberate act. He took his own life in a waterway at Downham Market by drowning himself.'
Outside court, Mrs Whelan said her son's death had left her heartbroken. Mr Whelan's father Thomas, who is divorced from Mrs Whelan, declined to comment.
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