A coroner has criticised a mental health trust for failing a man who jumped to his death from the Castle Mall shopping centre in Norwich.
At yesterday's city inquest, Norfolk coroner William Armstrong criticised the Norfolk and Waveney Mental Health Trust for 'fundamental deficiencies' in the way it treated Matthew Dunham, 25.
Mr Armstrong said support had been 'fragmented and unco-ordinated' with mental health staff not aware they were treating Mr Dunham at the same time, and therefore not sharing information.
The coroner also expressed concern that an emergency GP referral that should have been followed up within four hours, instead took two days.
He said: 'There is evidence of a disturbing nature as far as mental health services are concerned.
'There was no lack of help being given to Mr Dunham, but the care and support was clearly fragmented and unco-ordinated. The evidence reveals problems accessing information and about sharing information. These are fundamental deficiencies and serious inadequacies that must be addressed. It's alarming that information about a patient's care was not being shared.'
He concluded that Mr Dunham intended to kill himself, but added that it was while suffering from a mental disorder and while in receipt of mental health services.
A spokesman for the trust said at the inquest that changes were ongoing to rectify the concerns raised to ensure that it would not happen again.
Earlier, the inquest was told how shocked shoppers at Castle Mall were left traumatised by what happened, at about 7.20pm on May 9.
Mr Dunham had jumped from the fifth floor of the shopping centre landing on the ground floor level, and despite the best efforts of medical staff, he died at the scene.
The inquest heard that Mr Dunham, who was an IT web designer, lived alone at a flat in St Augustine's Street, Norwich.
Just seconds before he jumped to his death, he texted friends saying, 'It's over. Thank you all for being amazing friends. I would not have lasted this long without you.'
His friend Kimberley Myhill said his mental health had deteriorated earlier that year.
He was not happy with his accommodation or his job, and she said she convinced him to visit a doctor who prescribed anti-depressant tablets.
She spoke to him on the day he died at about 12.30pm, and he told her he was being evicted from his flat because he had not paid the rent.
The inquest was told that Mr Dunham was being treated by Lauren Lawrie, a psychological well-being practitioner with the trust, who spoke to him on the phone on April 24.
She said he told her he had suicidal thoughts, that included jumping off Castle Mall, and she assessed him as being a seven out of 10 risk, which meant he was more than likely to act on his thoughts.
She told him to get an immediate appointment with his doctor, in order for him to be referred to the mental health assessment team, and she called the GP to make sure this was done.
Robert Carey, a mental health nurse, said he subsequently met Mr Dunham, but he did not think he was a suicide risk. He said he had not known about his involvement with Miss Lawrie, and referred Mr Dunham to the trust's 'fast team'.
The inquest heard that Beverley Hare, a charge nurse with the trust's crisis team, spoke to Mr Dunham on the night of April 24. Following her conversation with him, he was passed back to the assessment team and sent a letter to come in for an appointment on May 23.
Mental health nurse Derek Mitchell offered condolences to Mr Dunham's family, on behalf of the trust, and said that following his death lessons had been learned, and actions put in place, or contemplated, to make sure it could not happen again.
After the inquest, Mr Dunham's family said in a statement: 'We are heartbroken to know that Matthew went from a wonderful person to this in the space of nine weeks. Our son was an intelligent, caring person who sought professional help as soon as he realised he was depressed.
'Matthew's suicidal thoughts and actions were known to so many people but we are heartened to know that procedures and systems will be changed and upgraded as a result of our son's death.'
A post mortem examination was carried out and the cause of death was given as multiple injuries as a result of a fall.
• If you have feelings of anxiety and need help, contact the Samaritans on 08457 90 90 90
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