A coroner has flagged a gap in mental health provision after a man deemed "not unwell enough" for specialist help took his own life.

Terence Donaldson, 55, known as Terry, died in his own home in Second Avenue, Caister, on January 23 of this year after a worsening of his anxiety and depression dating back to July 2021.

During his inquest, assistant coroner for Norfolk Samantha Goward raised concerns that he had missed out on care from secondary services after he was said to be too ill for the nurse that was treating him, but not ill enough to qualify for anything more specialist.

At the inquest hearing held on Wednesday (October 12) she recorded a narrative conclusion saying Mr Donaldson had taken his own life while suffering a deterioration from his mental health, adding: "We do not know what he was thinking at that time."

She hailed the support of his family, but raised concerns.

"In particular one of my concerns is this gap in services," she said.

"Where someone has a very experienced nurse saying I've got someone who is too unwell for me, and secondary services saying he is not unwell enough for us, what happens to them in-between?"

The coroner stopped short of issuing a Prevention of Future Deaths report having heard the decision regarding who should treat a patient was now a multi-disciplinary one involving people from different professions.

The inquest heard a meeting at the trust was due to take place within 12 weeks to take on board the findings, and the coroner asked for an update by the end of January 2023 as to what actions had been taken.

She summarised evidence that had been heard earlier on September 28 relating to Mr Donaldson's multiple points of contact with his doctor and various services and clinicians.

He was prescribed medication for low mood and anxiety in 2015 but his condition deteriorated in July 2021 leading to an urgent referral to the mental health team in August. His family had also raised concerns on multiple occasions.

In the months that followed his condition fluctuated. At one point he said he could not get through another day, and by the end of December his GP noted he had "reached rock bottom".