A “GENTLE” man with paranoid schizophrenia killed himself after the “gross failure” of his carers, an inquest heard.

John Ashley had been under the care of a mental health team at the Sussex Partnership NHS Foundation Trust but took his own life after a “failure to provide him with the additional level of care he required”.

He had a “mental health crisis” in the year before his death and experienced hallucinations in which he though the devil was commanding him to hurt himself.

Senior Coroner Penelope Schofield recorded that the 57-year-old’s death was “contributed to by neglect”.

She said: “Mr John Ashley took his own life while suffering a deterioration of his mental illness. The deterioration was not fully appreciated by those treating him at Sussex Partnership Foundation NHS Trust.”

Following the inquest his sister, Anne Ashley, said: “In the year prior to my brother’s death, I knew he wasn’t getting the treatment he needed.

“In the final few weeks I was terrified for his safety. He was seriously unwell and needed help.

“Deaths of people experiencing mental ill health must be brought out into the open so that poor care can be put right, to save other patients and families from going through this suffering.

“Every human being has the right to life, and to a good life.

“John was a valued voluntary worker (with the Shelter shop in Worthing from 2002 to 2016) and, when well, enjoyed nothing better than helping people.

“He was a sensitive, gentle man, who once had a talent for playing the classical guitar.

“He will be remembered for his creativity, courageousness and kindness to others.”

Mr Ashley was prescribed clozapine, an anti-psychotic medication for treatment resistant schizophrenia, which together with regular outpatients’ appointments with his psychiatrist, seemed to manage his symptoms well for many years.

But in the year before his death he “ began to experience a mental health crisis” and missed doses of his medication.

He attended his GP three times asking for help and attended A&E. Once he attended following an overdose of medication.

But he was repeatedly assessed as presenting a “low risk” of self-harm.

Consultant psychiatrist Dr Mynors-Wallis told the inquest that Mr Ashley was “not low risk” because he was psychotic, expressing thoughts to harm himself and believing he was controlled by the devil.

On the Friday before his death, John was told he would get support from the “Crisis Team” over the weekend.

But this did not happen because the trust did not provide such a service.

Also following the hearing Deborah Coles, the director of INQUEST, a charity which “provides expertise on state related deaths and their investigation”, said: “It was clear that John was in extreme distress. He was calling out for help and yet was neglected by the services that should have been best placed to support him in his desperate situation. This is one of a series of damning inquest conclusions on deaths of people in the care of Sussex Partnership NHS Foundation Trust.

“The current system for implementing change is not fit for purpose. An independent national oversight body is urgently needed, to ensure official recommendations are systematically followed up and to prevent another family from experiencing this loss.”