We asked NSFT why John’s medical notes were not available to call handlers at NHS 111 and if they had advised him to call the out of hours service.

An NSFT spokesman said: “Our patient’s records are not made available to call handlers, and will only be accessed by an NSFT clinician. However, there are protocols in place whereby other health organisations can call NSFT to ask for advice. Under exceptional and appropriate circumstances, we would provide appropriate information to assist them in dealing with a caller.”

“It was documented that [Mr Worthington] was advised on December 21, 2016 that he could contact NHS 111 if he felt he could not wait to see his GP during normal working hours, in order to trigger a further referral through to CRHT. There was no specific care plan that stated he should call NHS 111.

“But Mr Worthington had also previously been given a crisis service telephone number, as well as having been given a duty worker phone number, and the MIND crisis helpline number.”