A man who took his own life on the A47 was turned away from mental health services 10 times in the last four months of his life, an inquest has heard.
William Hunter Rowe, from Norwich, died on January 29 this year after he stepped out in front of a Royal Mail van, having fled a crisis safe house via a bedroom window.
An inquest into his death heard that in the months leading up to the tragedy he was left feeling as though he was "banging his head against a brick wall" trying to access support.
And it heard of 10 occasions between October and January when referrals to different departments of the Norfolk and Suffolk NHS Foundation Trust (NSFT) - which provides mental health services - were closed while he was trying to get help.
TIMELINE OF A TRAGEDY
In a statement read to the court, his sister Fran Hunter Rowe described how her brother, known as Will, had a long history of depression and anxiety, which in the last months of his life worsened following the breakdown of a relationship.
However, despite experiencing dark thoughts, he was determined to try and overcome his struggles and was eager to access support.
On January 2, he was admitted to hospital following an incident of self harm and referred to the crisis resolution and home treatment team of NSFT.
A week later, on January 9, he was visited by a mental health nurse who offered a form of counselling - but told him he was joining a two-year waiting list.
Two days later, he was discharged back into the care of his GP.
Miss Hunter Rowe said: "This left him incredibly deflated. He felt like he was banging his head against a brick wall to get help."
She said as Mr Hunter Rowe's struggles became more acute, he temporarily moved in with his parents for support.
But on January 27 he left the home in a distressed state and headed towards the dual carriageway at Postwick.
After the family raised the alarm, police were able to intercept him and take him to A&E, where the mental health liaison team saw him.
The court heard the 53-year-old told staff he did not feel he could keep himself safe and needed to be watched.
He stayed overnight at the Norfolk and Norwich University Hospital before a place was found for him at Holly Tree House, a safe house facility run by Norfolk and Waveney Mind.
But at around 11am on January 29, staff at the facility witnessed Mr Hunter Rowe running away from the site, having clambered out of his bedroom window.
The court heard that since the incident, the windows at Holly Tree House have been fitted with restrictors as a safety measure.
A short while later, he stepped into the path of a Royal Mail van, which was travelling at around 60mph on the A47 near Easton.
David Buxton, a vehicle technician who was driving the van, told the court Mr Hunter Rowe had made eye contact with him in the seconds before the crash - and left him no opportunity to react.
Johanna Thompson, area coroner for Norfolk, concluded his death was suicide.
TEN MISSED OPPORTUNITIES
During the hearing, NSFT officials listed the ten referrals for Mr Hunter Rowe which were closed in the four months before his death.
These were: Four calls to the first response service; two contacts with the mental health liaison team at the N&N; two referrals from the liaison team to the crisis team; one referral from the crisis team to the city team; one referral from the first response service to the city team.
Following the inquest, Anthony Deery, chief nurse at the trust, said: “Following William’s tragic death, we conducted a thorough review to identify any safety actions required to improve the care we provide.
"As a result, we have reviewed trust and partner crisis referral forms to improve the recording of clinical information and the recording of the rationale for clinical decisions.
"Staff have also undertaken bespoke mental capacity training to further support clinical decision making."
'ROCK OF THE FAMILY'
During the inquest, Miss Hunter Rowe said her brother was the "rock of the family" - describing how he would always make himself available for any of his loved ones.
A procurement officer at Broadland Housing Association, Mr Hunter Rowe also served as a mental health champion for the organisation - using his own experiences of mental ill health to support his colleagues.
In a statement issued afterwards, his niece Lucy Hunter Rowe said he "loved fearlessly" and would "go to the ends of the earth to make someone he cherished smile and laugh".
She said: "The most important lessons he taught me are to talk and listen. To not just share the good moments, but the dark too.
"Uncle Will was one of the best listeners I will ever know. If he knew someone was having a bad time, he made sure they knew they were loved and that they were heard.
"The system failed my uncle, but that does not mean it will fail you. Seek help early."
She added that the family is "beyond devastated" at the loss of Mr Hunter Rowe.
Do you need support? Samaritans can be reached at all hours on 116 123. The NHS First Response Service is available on 111 option 2.
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