A FATHER of six who “felt that the system had let him down” hanged himself in Winchester woodland less than a month after another suicide attempt, an inquest was told.

Senior coroner Grahame Short said Russell Duncombe “had given up hope that his problems could be cured” while also citing a “lack of joined-up thinking” leading up to his suicide.

Mr Duncombe had called an ambulance on October 12 last year and was taken to Royal Hampshire County Hospital in Winchester, with ambulance staff regarding him a high risk of suicide. But this was not communicated when nurses carried out a handover. Nor was a risk assessment done as this was not standard practice at the time. Mr Duncombe absconded and hanged himself nearby.

The inquest heard that he led a “chaotic” life with a history of alcoholism which was exacerbated by the deaths of his grandparents and his father in 2015.

After a suicide attempt in March last year he was referred to the mental health team who noted he had some symptoms of depression but they fluctuated and so he was not diagnosed with a mental illness.

Mr Duncombe again tried to end his life on September 19, attempting to hang himself near Andover police station. He was then taken to hospital where he was put on a detox programme, but after a few days he absconded and drank alcohol, effectively ending the detox.

Mr Short said “the clues were there” for the A&E nurse to have been aware of the increased risk, as she knew he had previously attempted to hang himself.

Mr Short added that nobody who was present on the night of his death took an “overview of Russell’s problems” and nor did they recognise that his “deteriorating behaviour” could lead to suicide.

However, he also said there was “no clear evidence that if there had been that approach it would have prevented his death”.

Speaking after the inquest, Mr Duncombe’s partner, Joanne Rogers said: “He should still be here.Everyone turned a blind eye. He said, ‘I’m just a statistic that you can write off your list’ and he was right. He was ignored.”

Julie Dawes, chief nurse at Hampshire Hospitals NHS Foundation Trust, said: “This is a very sad incident and our thoughts are with the family and friends of Mr Duncombe at this difficult time. We carried out our own comprehensive investigation into Mr Duncombe’s treatment and have already made changes to improve the way we care for patients in this situation.”


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