A vulnerable patient from Norfolk with suicidal thoughts was found dead in a broad after being let down by two trusts in East Anglia, an investigation by the Parliamentary and Health Service Ombudsman has found.
Renowned author, Stephen Foster, went to Norfolk and Norwich University Hospitals NHS Foundation Trust with his partner because he was feeling suicidal and admitted as an acute patient.
He was on the ward for more than 16 hours without adequate support.
He was eventually assessed by a doctor and then waited all night for the crisis team from the neighbouring trust, Norfolk and Suffolk NHS Foundation Trust, to see him and they did not attend until 9am the following morning.
He was assessed by a mental health nurse who discharged him and recommended he attend his GP surgery and get counselling.
Mr Foster was found dead three days later at Whitlingham Broad near Norwich.
The Parliamentary and Health Service Ombudsman found the initial treatment completed by the Norfolk and Norwich University Hospitals NHS Foundation Trust was inadequate.
However the decision to not detain the man under the Mental Health Act was reasonable.
Norfolk and Suffolk Trust's crisis team's failure to attend the man was unreasonable particularly given the length of time he waited to be assessed.
The eventual assessment and discharge completed by the mental health nurse was not comprehensive.
Stephen Foster's partner Trezza Azzopardi spoke to ITV News Anglia about the way she felt Stephen was treated after he was admitted to the Norfolk and Norwich Hospital feeling depressed and saying he felt suicidal.
Click below to hear from Trezza Azzopardi
The Ombudsman Service recommended both Trusts apologise to the woman and tell her the lessons they learned from her complaint.
They were asked to submit action plans to meet their obligations under the NHS Mental Health Crisis Concordat – a set of standards patients should receive in crisis care.
Click below to watch a report from ITV News Anglia's Malcolm Robertson