A mental health patient who killed himself while out on hospital leave had tried twice before to take his life when allowed home, an inquest heard today.

Ian Dugdale, 47, of Heatherbank Avenue, Keighley, was found hanged on March 13 this year while still a voluntary patient at Airedale Centre for Mental Health.

He had also taken a toxic level of prescribed anti-depressants.

His death triggered a ‘serious untoward incident’ report by Bradford District Care Trust and has led to more support being given to patients on leave at home, rather than checks on their progress being carried out by phone from the hospital ward, the inquest in Bradford was told.

Mr Dugdale's partner, Christina McArthur, told the Coroner’s Court he should never have been let off the ward and she felt her concerns had not been listened to at the time.

She asked his consultant psychiatric consultant Dr Jeremy Hyde, who was giving evidence: "How many times does it take for someone to try to kill themselves before alarm bells start ringing?

"Four times he tried, twice while on leave from the ward, on the fifth occasion he succeeded. It feels I wasn't listened to.

“He should not have been out. Ian was never better. He was always agitated. I tried to tell the nurses that."

Dr Hyde said the hospital had tried to slowly rehabilitate Mr Dugdale and there had been no pressure to discharge him from in-patient care – despite having to justify beds being occupied for more than six-week stays and with more money from the Trust being channelled away from ward care and into caring more for patients in the community to avoid people becoming institutionalised.

In response to Mrs McArthur’s belief she was not listened to, Dr Hyde replied: "It's something we need to get better at – it's not just Mrs McArthur."

He said people could not be "locked up forever" and Mr Dugdale had told them he was "fine" but would not speak about his emotions, making it difficult to understand what he was really feeling.

Recording a verdict of suicide, Assistant Bradford Coroner Dr Dominic Bell said: "It's very dificult for me to believe there had been any neglect on behalf of the mental health care organisation. It's clear the organisation has understood its governance responsibilities by having conducted an investigation."

After the inquest, Allison Bingham, deputy director of Bradford District Care Trust In-Patient Services, said: “Our thoughts and condolences are with the family at this difficult time.

“At the time of the incident we conducted an internal investigation which concluded that this incident could not have been prevented and there was no shortfall in the care offered to Mr Dugdale. The Coroner accepted these findings.”