Published: 11:00, 04 April 2014
Two NHS trusts have admitted "unacceptable failures" in their care of a father-of-two found hanged in a disabled toilet in Kent and Canterbury Hospital.
Simon Willson, 34, had been admitted to the hospital in January 2010 after taking a drug overdose.
But he was moved out of the A&E department after four hours "to meet targets" without being seen by a mental health professional.
An inquest last year ruled there was inadequate evidence to conclude Mr Willson had taken his own life because of his mental state at the time.
Now the NHS Litigation Authority has agreed there was negligence in the way Mr Willson was treated.
It says the East Kent Hospitals University NHS Foundation Trust and the Kent and Medway Social Care Partnership Trust admit there were failures throughout his time in their care.
The handover between units was unacceptable and there had been an inadequate evaluation of him from the outset, despite him being severely depressed and at risk of suicide.
The litigation authority said that when Mr Willson was moved from A&E on January 23 to meet targets, the handover between units was unacceptable.
The former floor layer, who lived in Knight Avenue in the city, had been known to Canterbury's mental health services since 2008 and had a history of drug and alcohol abuse.
It had led to several previous suicide attempts including one in 2009 when he was admitted to St Martin's Hospital in Canterbury, run by the Kent and Medway Social Care Partnership Trust.
On the morning of his death on January 23, 2010, Mr Willson went to Canterbury police station wanting to be sectioned. He was taken to St Martin's, but later discharged.
But he took an overdose on the same afternoon and was admitted to the Kent and Canterbury Hospital, run by the East Kent Hospitals University NHS Foundation Trust.
Mr Willson was then able to kill himself in a disabled toilet while unsupervised by hospital staff.
His widow, Melanie Willson, 33, said: "Simon was badly let down by the whole system - historically by mental health services and on the evening he died, by A&E.
"He so desperately wanted to get better and was looking for help but simply did not get it.
"On the evening he died they seem to have got everything wrong and nothing right.
"He would still be with us today if he had been shown the care and compassion you would expect and had people done their jobs properly.
"I truly hope that lasting lessons have been learned so that another family doesn't have to suffer as we have and will continue to in the future.
"Simon was a loving husband and father and the girls and I miss him terribly and think about him every day and always will."
Solicitor Nick Fairweather, who is representing the family, said: "It is both remarkable and deeply upsetting that such a sequence of repeated errors could have taken place, with Simon’s care, on the evening that he died.
"It is very important that those working within A&E have proper training and liaise thoroughly and effectively with their colleagues from Mental Health Services.
"There was a complete breakdown in communication between the two services in Simon's case. But for this, he would be alive and with his family today."
East Kent Hospitals University NHS Foundation Trust spokesman Gemma Shiletto said: "We have made a number of changes following an internal investigation.
"They include improved liaison from the mental health trust where a patient needs to attend an emergency centre, providing extensive training to emergency staff in the care of mental health patients, implementing a mental health assessment for patients presenting with mental health issues and minimising access to self-harm items for vulnerable patients."
Kent and Medway NHS and Social Care Partnership Trust spokesman Femi Adedeji said: "As this case is currently subject to legal proceedings we are unable to comment further at this stage, except to say that we wish to express our sincere condolences to the family for the loss of their loved one."