MISSED opportunities and human error played a part in the suicide of a depressed Bracknell man earlier this year an inquest heard.

The death of 35-year-old Alan Peter Day at his home in Poyle Gardens sparked a serious incident review into the workings of the Bracknell Mental Health Team after it emerged his mother had raised concerns about his condition just 24 hours before he died.

Adjourned on July 2, the resumed inquest on Wednesday, September 30 heard how several 'missed opportunities' including assessment notes missing from computer records and poor messaging systems may have contributed to Mr Day's death on January 29, 2015.

The coroner also heard he had been referred to group therapy in January 2014 but was still waiting to be transferred to it on the day he died.

After struggling with depression for around 15 years, Mr Day was found suffocated in his bedroom with a note saying, "I want everyone to know they couldn't have done anything to prevent this," adding, "I can't take anymore". 

His mood had deteriorated after his father Peter was diagnosed with a serious health condition and the family decided to sell their home.

The message left with the mental health team by his mother Janet Day on January 28 was not marked as urgent, the inquest heard, as the computer system had recorded his condition as 'low risk' and her call was not returned by Mr Day's psychiatrist Dr Ramley until the day after he died.

Dr Ramley said: "It was a typical case of depression. 
"In October 2014 his risk level was increased to medium because of his suicidal thoughts but he said he was too scared to act on them.

"Unfortunately at the time I was not able to detail the risk assessment form onto the system but I did detail it to his the GP at the time.

Asked whether there was a digital version of the assessment Dr Ramley said: "No, it was only hand-written."

She added: "I am now giving more time to make sure I detail my notes onto the computer. In hindsight my hand written notes should have been put into the system."

By November 2014 Mr Day's risk was reduced to 'low' after he reported a normal mood with no suicidal thought.

However Mrs Day said: "We did not see any improvement in his mood at all. After 15 years of depression to say that he had got better just doesn't seem right."

The serious incident review, conducted by the head of psychological therapy at the Berkshire Healthcare Trust Mark Hardcastle, put into place an action plan to improve the service.

Following evidence from Dr Ramley and Mr Hardcastle, Alan's father Peter Day expressed his shock at the state of the Trust's management.

He said: "I'm an ex-management consultant and I could come in and drive a bus through your processes. It would take me five minutes to sort it out. The fact this inquest was delayed has caused extra untold stress and grief. Mr Hardcastle has been very open and very thorough in his report and we thank him for that."

Recording a narrative verdict, Peter Bedford dismissed any claims of neglect and said: "I will record that he took his own life while suffering depression.

"There was a delayed response to Mrs Day's message of concern on January 28 and that in turn led to a missed opportunity for clinical staff.

"The fact that changes have been made and one of the doctors involved felt the need to change her practices, it would be wrong for me to not raise them in my conclusion.