Happisburgh man died after being struck by freight train

A wife wept as she told an inquest how her depressed husband's plea to be kept 'safe' in hospital was rejected days before he apparently jumped in front of a 75mph freight train.

Peter Bane, 47, of Happisburgh, was killed when he stepped off a platform at Witham railway station in Essex on February 16 last year.

His worried GP had urgently referred him to Norfolk & Waveney Mental Health NHS Foundation Trust's crisis team on February 5 but vital information about him planning to jump in front of a train was not recorded by non-medically trained receptionists.

Mr Bane, of Whimpell Street, a senior road safety officer with a London consultancy, was assessed over the phone by an emergency mental nurse later that day.

The inquest at Chelmsford Coroner's Court heard that she told him a place at Hellesdon Hospital, Norwich, 'was not for him at this time'. She arranged for more medication and a referral to a mental health link worker.

His weeping wife, Angela Bane, who had celebrated hers and Peter's 14th wedding anniversary on Valentine's Day 2009 - two days before his death - told the coroner: 'He should have gone into hospital, that's all I can say.'

She said: 'I heard him say what his plan was, to jump in front of a train. He didn't feel safe at home and he wanted to be admitted into the hospital to be safe.'

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She continued: 'He was not admitted. They said it was not for him at this time and he needed more medication.'

Mrs Bane added that over that period she made sure she was constantly with her husband because of her fears.

The crisis nurse Anna Thorne did not give evidence. Her one-year contract had ended and she is now in Australia, the inquest heard.

Her line manager at the trust Gary Hazelden said from her notes of the conversation he concluded Ms Thorne had assessed him as medium to high risk.

He added: 'Initially all urgent referrals are conducted by phone. Initial triage assessments are not automatically seen face-to-face.'

The emergency nurse could have arranged another assessment with a view to him being admitted that day, treatment at home, or follow ups with a link worker or other agencies. He said on average only one in ten were triaged face-to-face.

'Hospital is seen as a last resort, depending on the risk factors,' he told the inquest.

Mrs Bane, who attended the inquest with two of her three children and other relatives, said in evidence her husband's medication had kept his depression under control. He had suffered from the condition since he was a teenager and had three times tried to commit suicide, in 1981, 1987 and 2003.

However, she said his condition had deteriorated and he had been off work from October 2009.

On February 4, 2010 he told her he wanted to jump in front of a train and they went to the GP. At 7am next morning she woke to find him banging his head on the bathroom sink.

They immediately went back to the doctor, who referred him to the mental health crisis team on 5 February.

GP Dr Satish Singh, of the Staithe Surgery, Stalham, told the inquest: 'I felt strongly he was at immediate and grave risk.'

After a number of calls he spoke to someone at the crisis team and said Mr Bane needed to be assessed immediately. He said he told the person Mr Bane had strong thoughts about jumping in front of a train and wanted to be admitted to hospital. As a matter of routine he would have mentioned his previous attempts, he added.

From past experience, he expected that to be an assessment in person and was surprised when he learned it wasn't. He said that with hindsight he wished he had questioned it more.

'I was shocked to learn that he had died,' said the doctor.

The inquest, before a jury, is expected to end today.