THE shortcomings of an NHS mental health service's support for a father-of-four in the days before he took his own life likely contributed or caused his death, an inquest heard.

Matthew Collings was discovered by a dog walker in an area of woodland opposite Setley Pond near Lymington on February 25.

Winchester Coroner's Court heard Mr Collings, 54, had been referred urgently to Southern Health Trust's mental health services by a GP following a previous attempt to end his life at the start of the month.

However, a serious incident reporting investigation by trust practitioner Louise Earl read out at the inquest confirmed the referral had been downgraded, with no notes explaining this decision.

Following a multi-disciplinary team meeting on February 21, attempts from the service to contact Mr Collings were not made until February 25 after he had died.

The inquest heard that the "suboptimal delivery" of support could have "caused or contributed" to Mr Collings's death.

The trust said it has put a plan in place to address issues in their service, which included decision-making processes and communication with families and GPs.

Over the final months of his life, Mr Collings, a boat builder from Lymington, battled bouts of "acute" depression and anxiety, the inquest heard.

In 2018, he had separated from his wife of more than 20 years, Juliet Collings, but was still living in the family home on good terms. He had worried about finances and stressed about his job.

He had started a relationship with another woman in late 2018, which Mrs Collings supported and hoped would be successful.

Mrs Collings said her husband's mental health declined around Christmas and described him as a "desperate" man shortly before his death.

Pathologist Dr Vipul Foria gave a cause of death of hanging. Toxicology tests showed Mr Collings had the expected levels of medication relating to the prescribed drugs he had been given to treat his mental health at the time of death.

Acting area coroner Samantha Marsh recorded a verdict of suicide.

Discussing Southern Health's report, she said: "Had Matthew and his family received the immediate, timely and affective intervention and support it is highly likely but not known for certain that the outcome would have been different."

Following the inquest, Mr Collings's family paid tribute in a statement.

They said: "Matthew was a creative, energetic and adventurous man, kind, caring and loving to family, friends and colleagues. Although Matthew sought support from mental health services, it did not materialise quickly enough to help him. His untimely death is beyond sad and he is, and always will be, held dearly in the hearts and minds of his bereft family and all those who knew him.

"The family wishes to urge you all to listen to and look out for those who experience mental health difficulties and pain, particularly men, and respond quickly and robustly, with compassion and determination to help them find active support."

Dr Jeremy Rowland, Southern Health's medical director, said: "Whilst we know words will offer little comfort, we would like to offer our deepest condolences to Matt’s family at the incredibly difficult time.

"Our investigation into Matt’s care revealed that we did not provide the service he or anyone under our care deserves, and for this we apologise. The findings of our investigation have led to a number of changes, including involving families more to better understand risks and full discussions with relevant colleagues when receiving referrals or changing aspects of a patient’s care.

"Matt’s tragic death highlights the need to continuously improve our services and reinforces the vital importance of suicide prevention."