A Health Trust has been ordered to take action after a coroner concluded a mentally ill man took his own life following “a number of failings” in his care.

31-year-old Daniel Futers, who had a history of mental illness, fell to his death while on leave to his family from Sunderland’s Hopewood Park Hospital in April 2022.

He was due to return to the Ryhope hospital, run by Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, the following day.

In the days before her son’s death Dawn Futers called the unit several times concerned that Daniel seemed anxious. However, she was reassured that all was fine by the hospital staff, an inquest was told.

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Coroner Derek Winter recorded a narrative conclusion in which he said Daniel “took his own life in part because the complexity of his condition was not fully appreciated, and appropriate precautions were not in place to prevent him from doing so.”

Mr Winter issued a prevention of future deaths report calling on Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust to set out what action it would take to improve patient safety.

However, the Trust has responded to the coroner saying it was “disappointed” at the report. It added it already had “appropriate systems and safeguards in place”.

Ms Futers, 56, of South Shields, has now for lessons to be learned. She’s also spoken of her disappointment at the Trust’s response to the coroner’s findings.

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She said: “It’s almost impossible to find the words to describe the hurt and pain our family feel following Daniel’s death.

“What happened to Daniel is something that will stay with us all forever and is something we’ll never get over. The hardest thing to try and come to terms with is that when Daniel needed help the most he was let down.

“It felt like the hospital wasn’t really listening to my concerns despite being Daniel’s mum and knowing him better than anyone.”

Daniel had been known to mental health services since 2008. He had been admitted to hospital under the Mental Health Act several times between 2014 and 2020, and each time he was diagnosed as suffering from psychosis and schizophrenia.

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Daniel was admitted to Hopewood Park in February 2022, and placed in the psychiatric intensive care unit (PICU).

After being allowed out of hospital on escorted day leave, plans were made for Daniel to be allowed a week-long home visit ahead of being released permanently.

On March 29 – the day before he was due home – Dawn raised concerns Daniel seemed anxious. However, she was reassured and Daniel’s leave went ahead during which he would return to the hospital to receive medication.

Dawn continued to express concerns about her son. On April 1, Daniel was supposed to receive his medication but Trust staff were unable to make the appointment. He was told to return the following day, Sunderland Coroner’s Court was told.

On April 2, Daniel received his medication. Later that day Dawn phoned the hospital raising concerns about Daniel, the hearing was told.

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Three days later, on April 5, he was seen on Wearmouth Bridge, and emergency services were called. Daniel was pronounced dead shortly afterwards.

The coroner found there had been “a number of failings” in Daniel’s mental health care and treatment “in particular the management of his leave from Hopewood Park and his prospective discharge from state detention.”

Rajesh Nadkarni, Executive Medical Director and Deputy Chief Executive at CNTW, said: “Our thoughts and sympathies are very much with Daniel’s family and friends at this difficult time.

“The Trust takes all patient deaths very seriously and investigates them rigorously to establish if lessons can be learned or services can be improved.

“We will reflect on the family’s comments and look at how we can further improve the care we provide to our patients whilst they are transitioning from hospital back into the community.”

Joe Haley, the medical negligence expert at Irwin Mitchell that is representing the Futers family, said: “Dawn and the rest of Daniel’s family remain devastated by his death and the circumstances surrounding it.

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“Sadly the inquest found failings in Daniel’s care with the coroner concerned enough to order the Trust to set out what action should be taken to prevent future deaths.

“Dawn is particularly upset by the Trust’s response to this and believes more still needs to be done to protect others.

“People under the care of mental health services are some of society’s most vulnerable and it’s vital that the highest standards of patient safety are maintained at all times.”