The family of a man who took his own life have said they are devastated by the “numerous failings” in his mental care.

Following the inquest into the death of 26-year-old Peter Cottington, his family described feeling let down by the many services he reached out to for help.

Mr Cottington’s sister, Louise Cottington, said: "Peter was an intelligent, articulate and insightful young man who was constantly seeking help for his mental health.

"We are devastated to learn of the numerous failings from every service he encountered, ultimately leading to Peter slipping through the many cracks in our mental health services, thus contributing to his tragic death.

"Peter is sorely missed and we continue to advocate for him and others suffering with mental health issues by raising money for Norfolk and Waveney Mind."

The inquest also heard that a number of pieces of information about his care had not been shared between NSFT, his GP and probation services during this period - largely due to different recording systems being used.

Yvonne Blake, area coroner for Norfolk, said: "It seems nonsensical to me that GPs and the mental health trust do not use the same computer systems."

Mr Cottington, of Mattishall near Dereham, died after being found hanging on September 6 last year.

The inquest heard that he suffered a number of traumatic events in his life, including the loss of a child, falling victim to abuse as a child and being stabbed as an adult.

These traumas led to him developing deeply complex mental ill health, including post-traumatic stress disorder, anxiety and depression.

He had been under the care of the community mental health team at the Norfolk and Suffolk NHS Foundation Trust.

But while on remand, his care was transferred to the prison wellbeing service - a separate department of the trust.

On his release after receiving a suspended sentence, he was not referred back into the community team and his care fell away.

The court heard Mr Cottington's mental health again deteriorated in August 2022 which saw his partner phone the police amid concerns for his safety.

On August 31, he underwent a Mental Health Act assessment after being detained by police - but was judged not to be suffering an acute mental health incident.

John Champeney, one of the psychiatrists who assessed him, said that while he was "distressed", he did not appear in a "state of crisis".

The following day, he attended his GP in Mattishall after adult social services alerted the surgery to the previous day's incident.

Elizabeth Jones, the GP who saw him made an urgent referral to mental health services - which should be responded to within five days. 

However, this referral was not made until four days later - and not received by NSFT until September 6, an hour after his death.

Giving a narrative conclusion, Mrs Blake said: "Peter took his own life.

"He should have been under the care of the community mental health team but this had not occurred.

"He was assessed by two psychiatrists who felt he did not have an acute mental illness and his GP felt he did not have signs of acute mental illness.

"It is acknowledged there were delays in his referrals but it is not clear if this affected the outcome."

Maeve Sykes, representing NSFT, said the trust "apologised unreservedly" for the breakdown in his care after his release from prison.

If you need help and support, call NHS 111 and select option 2 or the Samaritans on 116 123. Both services are available 24 hours, 7 days a week. You can also download the Stay Alive app on Apple & Android.