Published: 00:01, 14 May 2016
Mental health professionals called to help a distressed man who had attempted suicide went to the wrong house.
Days later, David Ashley killed himself in a field at Hothfield Common.
An inquest into his death heard the team's computer system to look up his address had broken down.
There were also other problems, such as there not being enough crisis team staff to answer phones.
Rachel Redman, Central and South East Kent coroner, said: "I am satisfied beyond reasonable doubt that Mr Ashley intended to take his own life.
"In terms of the concerns raised it seems that most have been addressed except for the matter of additional staff."
Mr Ashley, 54, was found dead in a field at Hothfield Common in Ashford last August.
"It was pitch black and we were relying on iPhones for torches. No one appeared to be home so there was no contact" - Graham Caney
He had died as a result of wounds which Detective Sergeant Matthew Smith said were consistent with being self-inflicted.
Dr Elizabeth Russell, community psychiatrist, told the hearing at Folkestone Magistrates Court that, on August 10, Mr Ashley had gone to a weir at Maidstone to drown himself.
But he panicked when he got into the water and shouted out. He was saved when witnesses called the police.
Dr Russell was called out to see him after he was taken to Maidstone Hospital, and described him as distressed and in a low mood.
She said she noticed tremors from Mr Ashley's alcohol intake and that he was badly affected by his brother's death.
He was also distressed that he had fallen out with his long-term friend Nigel Chapman and would have to move out of Mr Chapman’s home in Westwell Leacon near Charing. He was staying with another friend in the last three days of his life.
Graham Caney is part of the South East Kent crisis team for Kent and Medway NHS and Social Care Partnership Trust, based in Ashford.
He and colleague Judith Hudson had gone to see Mr Ashley at about 1am on August 12 at Mr Chapman's home.
But they had gone to the wrong house - another property owned by Mr Chapman across the road, which was empty.
The computer system at their base, which had Mr Ashley’s correct address, had broken down.
Mr Caney said: "We would have had his full address and contact details. But it was pitch black and we were relying on iPhones for torches. No one appeared to be home so there was no contact."
The inquest heard other professionals including police had the wrong address.
Mr Ashley was seen during the day on August 12 by crisis team specialist Dr Hassan Taha, at a meeting at Ashford Gateway Centre.
He concluded that Mr Ashley was not suicidal.
The crisis team had tried to make follow-up contact with Mr Ashley right until the last day of his life.
But Mr Caney also told the hearing that at times only two out of the team’s phone lines at Ashford could be answered because there was not the staff, especially when they were out visiting clients.
The inquest heard that there had been improvements since the tragedy, with the affected IT system being made more stable and being backed up by another system.
For confidential support on an emotional issue, call Samaritans on 116 123 at any time.