The father of a 35-year-old man who took his own life less than 48 hours after nurses discharged him from hospital has pleaded for lessons to be learned about the care of people with mental health problems.
Andrew Bellerby was taken to A&E at Sheffield's Northern General Hospital in July 2015 after staff at a pharmacy in the city became so concerned about him that they called an ambulance.
His father, Richard Bellerby, said that his son was having suicidal thoughts, had cuts to his wrists, had made a number of other recent attempts and was threatening to jump from a fifth floor window but mental health nurses decided he was not a risk and discharged him.
The 72-year-old company director said Andrew took his own life less than two days later.
After a two-and-half year battle, Mr Bellerby said Sheffield Health and Social Care NHS Foundation Trust (SHSCFT) has now settled a legal action and he has received an apology for failings that it has admitted, although the trust does not admit that these failings caused Andrew's death.
Now he said he is determined to make sure care services are improved.
Mr Bellerby, from Aldwark, North Yorkshire, said his son was "just a lovely boy" when he was a youngster, who doted on his younger brother, Robert.
But, after a private education at Bradford Grammar School, he "got in with the wrong crowd and went down the wrong road".
Mr Bellerby said that by his late teens Andrew was struggling with substance abuse and ended up in a rehabilitation centre in Sheffield, a city where he stayed.
He said that, despite better periods, he had an ongoing struggle with addiction and mental health issues including depression and paranoia.
When Andrew ended up in hospital in July 2015 he was discharged after two nurses used a method called the Crisis Triage Rating Scale (CTRS) as part of their assessment of him and deemed him not to be a risk, Mr Bellerby said.
He said the trust's internal investigation found that the nurses were not trained to carry out the CTRS assessment.
"That scale, with those untrained staff, was just the tip of the iceberg," Mr Bellerby said.
"That was just the last thing that happened before he took his life.
"It was a lack of care throughout the process of that particular trust dealing with our son's care."
He said: "The proof of the pudding is that within 48 hours he had taken his life."
Mr Bellerby said his son had more than a decade of contact with many different mental health and addiction-related services in Sheffield but likened their involvement to "musicians in a orchestra, all trained to play their instruments, all reading off their sheets but no conductor, nobody pulling it all together".
He said he believes his son needed an appropriate doctor to be clearly responsible for his coordinated care and this is a problem across mental health services more generally.
And he also criticised the attitude of the trust following his son's death, even down to the tenor of the letter of apology he eventually received earlier this year.
He said: "The experience has left us feeling that our son's life was worth nothing to the NHS and those responsible for Andrew's care."
The family's solicitor Samuel Hill, from law firm Irwin Mitchell, said the legal action was not about the money and the final financial settlement is small.
He said: "It was to ensure the trust were aware of what happened, to ensure the trust were aware of their failings and, ultimately, to make sure somebody else doesn't go through this situation again."
Trust chief executive Kevan Taylor said: "We would like to, once again, offer our sincere condolences to the family of Mr Bellerby."
He confirmed that an internal investigation highlighted "some areas where the delivery of care could be improved" and all actions identified in the wake of this have now been completed.
Mr Taylor said: "While we are unable to comment on individual cases, I can confirm that the investigation findings and recommendations were shared with Mr Bellerby's family.
"We would like to reiterate our apology to them for the areas of poor practice identified by the investigation."
Copyright (c) Press Association Ltd. 2018, All Rights Reserved. Picture (c) Sheffield Health and Social Care NHS Foundation Trust.