A man was failed by multiple agencies before he took his own life, an inquest jury has found.
Adam Stanmore, 37, from Oxford, had been suffering from a mental disorder before he was found dead in 2019.
At Oxford Coroner’s Court on Friday, a jury concluded a lack of information sharing by police, the ambulance service and other health services contributed to his death.
Mr Stanmore’s family said they were “shocked and saddened” by the failings.
The court heard on 18 May 2019, Mr Stanmore, who had type 1 diabetes, was Tasered by police during an arrest over reports he had a knife and was acting suspiciously.
The use of force was deemed reasonable at the inquest.
After being taking taken to a custody suite at Abingdon police station, paramedics were called over his low blood sugar level and he was de-arrested and taken to to hospital.
But Mr Stanmore asked to leave the ambulance and was reported missing four days later.
His body was eventually found in a wooded area a month later. The cause of death was determined to be hanging with an overdose of insulin.
On Friday a jury concluded there was an inappropriate handover of information between the ambulance control centre and paramedics, as well as officers and paramedics in the police custody suite – issues the jury said contributed to his death.
‘Catalogue of errors’
Mr Stanmore’s former partner, Laura Klee, said in a statement his family was grateful the jury had acknowledged the “catalogue of errors” in his care.
“While it is too late for Adam, we sincerely hope that changes occur as a result of learning and that Adam’s death will not be in vain,” she said.
She added: “It is evident that we have a long way to go in the understanding and treatment of people suffering with acute mental health episodes by the emergency services.”
Thames Valley Police said it would review the findings and recommendations of the inquest and take any necessary action.
South Central Ambulance Service NHS Foundation Trust apologised for the opportunities missed during Mr Stanmore’s care and said it had conducted an investigation and learning had already occurred.
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