The parents of mental health patient Christopher Higgins have said his death was 'tragic and avoidable' as an inquest jury returned a conclusion of suicide.
And Norfolk's senior coroner has highlighted four factors which could have prevented his death and require improvement within the sector.
The inquest heard how the 36-year-old, from Grimston Road, South Wootton, near King's Lynn had become 'psychotic and paranoid' in the months leading to his death, and had attempted to take his own life.
His mother, Ann, repeatedly tried to find help and said she had 'tried in vain to avoid a crisis occurring'.
Mr Higgins was only admitted as a voluntary patient to the Fermoy Unit at the Queen Elizabeth Hospital, in King's Lynn, after police were called to the family home on June 23, 2013.
He had been claiming the house was bugged, and attempted to cut the tyres from the car to check for devices. After being admitted, the former Bespak worker attempted to take his own life a number of times until diving from a railing outside the Fermoy Unit in the early hours of June 25.
'The whole thing has been hell,' said Mrs Higgins, 70, after the inquest. 'It is absolutely heartbreaking.
'This was an avoidable death. I am very angry and very bitter.
'Every time I phoned the GP it was like starting again, and there was no support whatsoever. Without realising it I was becoming paranoid myself.
'He knew his mind wasn't right, and we reached crisis point.
'He was suddenly talking about gang stalking, and he was really quite delusional.'
Mrs Higgins had visited her son at the Fermoy Unit just hours before he died, when he told her, 'Mum, I tried to take my life today'.
'I thought they were professionals and had trust they would look after him properly,' she added.
Mr Higgins's father, Jon, added that the care his son received was 'totally inadequate'.
'He should have been given urgent treatment,' he said. 'At that stage the whole system was in disarray, because there had been a reorganisation a month before, and the electronic records were not communicating with each other.
'It had been suggested he should take anti-psychotic drugs, but he was frightened of being poisoned so he would not take them.'
Mr and Mrs Higgins added they were 'totally unsatisfied' by the findings of a serious incident report, and called for an independent report, which they were denied.
Mr Higgins said: 'If we had got the help we requested over and over again it is probable Chris would not have had to enter the Fermoy Unit, but meaningful help was not forthcoming.'
Jane Sayer, director of nursing, quality and patient safety at the Norfolk and Suffolk NHS Foundation Trust, said: 'We are very sorry for the family's loss.
'We have learned lessons and already made major improvements to our services since Mr Higgins's death.
'We will continue to address any further issues that we have identified from the findings of the inquest.'
The EDP has been running a Mental Health Watch campaign this year calling for better local services in the sector.
The campaign launched in October this year and has gained support from both Norwich MPs, who have said there needs to be parity with treatment for physical health.
Need to talk? Call the Samaritans on 116 123.
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