Hospital staff 'could have done more' to help a man who was threatening to take his own life in the minutes before his death, a coroner ruled.
Daniel Kirton attended A&E to 'detoxify' from Spice but ended up getting killed when he rolled into a road outside Manchester Royal Infirmary where he was hit by a taxi.
A coroner has ruled that mental health staff who dealt with Mr Kirton were not guilty of 'gross failings', but could have done more.
The 35-year-old, who was homeless, was discharged following a mental health assessment on December 3, 2020.
Once outside, Mr Kirton told security staff he 'wanted to die'.
He was not re-admitted for further assessment, Manchester Coroners' Court heard, having earlier been deemed fit for release by Greater Manchester Mental Health NHS Foundation Trust staff.
Security remained with Mr Kirton until he left the hospital grounds around 11.35pm.
At 11.37pm, he rolled onto a road, before being hit by a private hire vehicle.
He was rushed back inside, but died at 12.57am on December 4.
His cause of death was given as 'chest injuries'.
Mr Kirton's death has been the subject of a coronial investigation. Mr Kirton's family were in court as the case concluded on Friday, Manchester Evening News reports.
Area coroner Zak Golombek told the court Mr Kirton was initially seen by members of the mental health liaison team at around 10.15pm.
He was 'calm and polite' during the initial stages of the assessment, saying he wanted to detox from Spice and address his homelessness.
Mr Golombeck referred to previous hearings, in which it was said there were no signs of depression or psychosis.
Mr Kirton, the court heard, started to become threatening when medics discussed discharge and offered community treatment.
Members of the hospital's security team overheard a 'commotion', Mr Golombeck said, and Mr Kirton was escorted from the building at around 11.15pm.
Once outside, he told staff on 'numerous occasions' he 'wanted to die'. Security staff stayed with him in a bid to calm him down and distract him, the court heard.
Mr Kirton attempted to take his own life on hospital grounds.
Security asked for members of the mental health liaison team to go outside see him, with one member of staff going to A&E in search of a medic.
"The security officers displayed integrity and went above and beyond their brief," Mr Golombeck said.
Mental health nurse Godfrey Chiveya saw Mr Kirton outside at around 11.23pm. Security told him Mr Kirton had said he wanted to take his own life. Mr Chiveya said he did not believe there was a threat to his life, Mr Golombeck said.
After around four minutes, they had reached an 'impasse'. Mr Chiveya told Mr Kirton he would be seen by a member of the community mental health team the next day and left.
"They thought the risk was the same as in A&E," Mr Golombeck said.
"The security didn't think they were taking him seriously, they didn't appear in control of the situation," he added.
Mental health nurse Cara Oates, from North Manchester General Hospital, investigated the case.
She said the mental health liaison team's assessment of Mr Kirton in A&E was reasonable, but interactions with him outside 'were not appropriate and he required further assessment'.
Reviewing the evidence, Mr Golombeck said the initial assessment was 'reasonable' and that it was an 'incredibly difficult' task to carry out considering Mr Kirton's aggressive behaviour.
The coroner said this impacted on the team's 'personal views' of Mr Kirton in a 'negative sense'.
The mental health liaison team's interactions with Mr Kirton outside the hospital were criticised throughout the hearing by those representing his family, but Mr Golombeck said: "There were failings outside the hospital building, but not total and complete failures - not gross failings."
He said Mr Kirton 'required further assessment' due to 'his presentation outside the hospital building'.
But Mr Golombek said he was unable to determine if Mr Kirton would have gone back to A&E, adding that he 'actively chose' to leave the hospital site when he could have gone back .
Recording a short form conclusion of suicide, Mr Golombeck said: "Daniel intended to take his own life when laying in the road. There was no significant planning to this and it appears to be somewhat impulsive, and done with the intent of ending his life."
At a previous hearing Mr Kirton's brother David said his sibling had 'struggled with mental health for a long period of his life', but was 'kind and compassionate'.
"He was someone who struggled with mental health for a long period of his life. He was kind, compassionate and would help out anyone," he added.
"He was a good brother, a good father and a good son.
"He wasn't perfect as a character but was a good person in his heart who was easily led astray.
"His mental health challenged him for a lot of his life."
