A man told staff at Tolworth Hospital he was “always thinking of suicide” hours before hanging himself.

An inquest heard how Stephen Smith, 38, of Revell Road, Kingston, left Tolworth Hospital on the night of February 21, 2012 telling staff he needed some “fresh air”.

His body was found the next day in Tolworth Court Farm playing fields by a dog walker.

Mr Smith was admitted to Tolworth Hospital in September 2012, with various periods of leave throughout, after being originally sectioned. He suffered from schizoaffective disorder.

West London Coroners’ Court judged today that the inadequacy of risk assessment at Tolworth Hospital has been found partly to blame for his suicide.

In the weeks before Mr Smith’s death family members were reporting to the hospital how they were “very concerned for his safety,” as he began showing high levels of stress and was struggling to sleep.

"We knew he would kill himself"

When questioned Dr Tracy Burrows, a doctor at the Lilac ward where he was being treated, maintained that there was always a “chronic suicide risk” with Mr Smith, though in the last two weeks of his admission he was displaying more sleep disturbance.

Mr Smith’s condition appeared to worsen after an unsuccessful trip to Manchester in December 2012, causing staff to reduce his leave.

Patients reported seeing him access suicide websites while on two occasions staff approached Mr Smith about odd behaviour. The coroner concluded that both were unsuccessful suicide attempts.

Ward manager Rosemary Ward said: “He often spoke of suicide. The thing that changed was his actions. We felt he was going through extremely difficult times.”

Primary nurse at the ward Sarah Green said that she did not see the need for Mr Smith to be re-assessed under the Mental Health Act after he was sectioned.

She said: “He came across to me as a very intelligent man who wanted to provide for his family. He wasn’t asking to leave, he was taking his medication and was open with nurses.”

Mark Bowman from Fieldfisher, solicitors for the family of Mr Smith said: "This remains a very difficult time for the family who request that their privacy be respected.

“The family had expressed concerns in the last weeks of Steve's life that he was significantly deteriorating and accept that the coroner found that the risk of Steve taking his own life was not adequately assessed and that this played a part in his death.”

“He will be greatly missed by everyone who knew him."

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