Dad-of-one Adrian Horsley was admitted to the Priestley Unit at Dewsbury and District Hospital following a deterioration of his mental health.
Around 11 weeks after his admission, Mr Horsley went missing from the unit, which is run by the South West Yorkshire Partnership NHS Foundation Trust, on March 22, 2019, after being permitted to leave the ward on his own.
He was found dead later that day at Dewsbury Train Station, aged 48
An inquest into the death of Mr Horsley, from Holmfirth, was held at Bradford Coroners' Court this week.
The inquest concluded that a number of failures in the care provided by the trust, which came to light during the course of the inquest, probably caused or contributed to his death.
Staff were unaware of the plan of care regarding leave due to a number of issues. Had they been aware, leave would not have been permitted.
The issues included failures of the electronic patient information system which meant that staff were unable to access Mr Horsley’s records, the absence of a written handover sheet, limited information being provided on shift handover and staff relying on information which was 48 hours old.
Rebecca Jones, the specialist medical negligence lawyer at Irwin Mitchell representing Mr Horsley's wife Jemma, said after the hearing: “Losing Adrian so tragically has left his loved ones struggling to come to terms with what happened.
"The past three years have been incredibly difficult for his family, in particular Jemma, who has many questions regarding his death.
“While nothing will make up for her loss, we’re pleased to have been able to help provide her with the answers she deserves.
“People with mental health issues are some of the most vulnerable in society. Sadly the inquest heard worrying evidence surrounding the events that unfolded in the lead up to Adrian’s death.
"It’s now vital that lessons are learned to help improve patient safety so that others don’t have to go through what Adrian’s family have.
“We’ll continue to support Jemma as she attempts to come to terms with her loss.”
Mr Horsley, who worked as a lightning protection engineer, had previously suffered from depression and was diagnosed with bowel cancer in November 2017. He underwent chemotherapy and surgery, and had a temporary stoma fitted.
The inquest heard that he struggled with his diagnosis and suffered anxiety regarding his stoma bag. By December 2018 his mental health had deteriorated further and Mrs Horsley said he expressed suicidal feelings.
During the early hours of January 3, 2019, Mr Horsley was admitted to the Priestley Unit.
On March 19, following further suicidal comments, the hospital agreed that Mr Horsley should not be allowed to leave the leave the ward unless accompanied by a member of staff, for his own safety.
Three days later, Mrs Horsley said a consultant phoned and informed her that her husband was missing from the Priestley Unit. He was found dead later that day at Dewsbury Train Station, the inquest was told.
The decision to allow Mr Horsley to leave the unit was against his doctor's advice and his doctor told the inquest that, as far as he was concerned, any change to this decision should have gone through him.
Prior to his death, Mr Horsley had been married to Jemma for 24 years. They have one daughter, Emily, 21.
Mrs Horsley, 50, said: “It’s been more than three years since we lost Adrian and he is still very much missed by all of his family. He has left a huge hole in our lives.
“Adrian was a wonderful husband and father but had started to struggle following his cancer diagnosis.
"When he went into hospital we really thought Adrian was in the best place possible to receive the support he needed.
“While the inquest was difficult having to relive everything, we’re grateful that it’s over and we at least have some answers.
"Sadly nothing will turn back the clock, so all we can hope for now is that something is learned from our tragedy so that others don’t have to suffer like us.”
Dr Subha Thiyagesh, medical director at South West Yorkshire Partnership NHS Foundation Trust, said “Our thoughts are with everyone affected by Mr Horsley’s death.
"The trust is very grateful to the coroner for the very thorough inquest he has conducted and accept his conclusions.
"Shortly after Mr Horsley’s death in 2019 the trust commissioned a very thorough investigation into the circumstances and, as acknowledged by the coroner at the conclusion of the inquest, the trust has worked hard to implement all of the recommendations arising out of that investigation.
"This will minimise the risk of a recurrence of these tragic circumstances.
"The trust extends its condolences to all of Mr Horsley’s family and friends at this time.”