Neil Leedham inquest
The family of a man who committed suicide in hospital is demanding to know why staff kept a suicide note secret for more than a year.
Neil Leedham, 41, of Oat Piece, Marston Moretaine, was found hanged by his own belt in the Phoenix Unit in Weller Wing, the Bedford Hospital psychiatric unit run by the Beds and Luton Mental Health and Social Care Partnership, on August 8, 2008.
But it was not until the first day of the coroner's inquest into his death that the NHS revealed that he had left a suicide note for his family.
His mother Helen Leedham said: "I cannot believe the callousness of anyone who would have knowingly withheld this information from us.
"If it wasn't upsetting enough to go to your own son's inquest, finding out that the authorities have been sitting on Neil's suicide note for over a year is heartbreaking."
Mr Leedham was admitted to the specialist facility after taking an overdose of tablets, drinking six cans of beer and trying to drown himself in a lake.
Mr Leedham had no long-term history of mental illness, but struggled to cope with losing his job as a logistics manager three months prior to his death.
In the days leading up to his admission to Bedford Hospital Mr Leedham made several claims that he would take his own life.
The family's solicitor, Kate Easy from Irwin Mitchell, said "There is no doubt that the family should have been told about a suicide note immediately.
"While there have been a number of different authorities involved since Mr Leedham's death, someone should have told the family and they deserve answers."
Pheonix Unit was only set up six months before Mr Leedham was admitted and was shut down following his death and a full investigation by the NHS trust.
Mrs Leedham added: "There was clearly a very high risk that my son would attempt to take his own life.
"He had been extremely distressed in the days before he was admitted to Bedford Hospital, with fears for his safety real enough for a police search to be called.
"We simply cannot understand why a man in such a vulnerable condition was left alone for such a long period of time.
"I have lost my son for the sake of mistakes in the most basic level of care."
Mrs Leedham accepted an out of court settlement from the Bedfordshire and Luton Mental Health and Social Care Partnership NHS Trust in March, but said she still wants to know why she was not told of the suicide note and who was responsible for keeping it from her.
Giving his verdict on Mr Leedham's death last week, coroner David Morris said: "There was no clear understanding of the purpose and function of the unit amongst the clinicians, let alone the staff who operated it, or the clients who used it.
"It was absolutely right to close it and start again."
The inquest also revealed there was a lack of risk management and assessment on the unit, a communication breakdown between A&E and Acute Assessment Unit crisis teams and a failure to manage and review ligature points in the unit.
Mr Morris recorded a verdict that Mr Leedham: "took his own life while he was clinically depressed."