A health trust said there are "things we could have done better" after a coroner ruled there were "missed opportunities" before a Southall dad died after being hit by a train.
Peter Docherty, who had a long history of schizo-affective disorder, died after leaning forwards from a platform at Ealing Broadway station into a moving train on January 7 2015.
The train was travelling 100mph when it struck the dad-of-one, who was heavily involved in Scientology, an inquest into his death heard earlier this month.
The hearing found Mr Docherty presented himself to Ealing Hospital A&E on January 4 2015, saying he was "not safe at home" and was "at risk" of jumping in front of a train.
He was then admitted as a voluntary patient to a ward under Hammersmith and Fulham West London Mental Health Trust (WLMHT) , where he "thereon" denied further suicidal ideation.
In her conclusion following the inquest, coroner Sarah Ormond-Walshe, said: "On the morning of January 6, after an MDT (Multi-disciplinary meeting) ward round, it was agreed (after assessment) that Peter could leave the ward to go home and get some belongings and also attend an AA meeting.
"He returned later that evening and was then allowed home overnight, without any further assessment.
"He went to Ealing Broadway Railway Station on the morning of January 7 2015 and leant forwards from the platform into the path of a moving train and died instantaneously.
"He was pronounced dead a short while later at 9.23am.
"His care coordinator was on annual leave at the time and no contact by the trust had been made with the family or friends upon his admission, during his admission or when he was allowed home on leave.
"Peter's family were unaware he had suicidal thoughts leading to this admission.
"There was, in this, and in not risk assessing him later in the day of January 6, missed opportunities to minimise Peter's risk to himself.
"There were also failures in relation to administering his medication and/or confirming that he had taken the medication himself.
"These last failures are not likely to have been causative of his death."
A spokesman for WLMHT said it has put in place measures to improve its service following his death.
The spokesman said: "Our thoughts are with Peter’s family at this difficult time.
"It is clear that there are things we could, and should, have done better in this case.
"We know that learning and improving is central to providing high quality care and that is why we continually need to look at all the care we provide and learn lessons wherever we can.
"We have already put in place a number of improvements to our processes following this case and will look closely at the full verdict to see what more we can do."
At the West London Coroner's court on Monday January 9 this year, the coroner's verdict was that Mr Docherty's death was as a result of self-harm.
The verdict was: "The coroner's verdict is the deceased carried out an act of self harm whilst suffering from mental illness."
Marc Docherty, Mr Docherty’s son, said at the conclusion of the inquest: "My dad was a lover of people with a kind and generous spirit.
"He was a fantastic father and a loving husband who will be sorely missed by all his family.
"The inquest process has been a hugely difficult experience for us, particularly given this week is the anniversary of my father’s death."
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