LINCOLNSHIRE'S mental health officials are carrying out a searching review of their practices after receiving severe criticism over their handling of a suicidal farmer.
William Varley shot himself at his farmyard on February 28, a week after Louth nurses failed to admit him to a psychiatric ward and sent him home.
It was revealed both his father and grandfather had also committed suicide.
A leading psychiatric professor said he was 'flabbergasted' Dr Varley, 57, of Girsby Top Farm, Ludford, was not admitted on February 21 after taking an overdose of tablets the previous day and being seen at Louth Hospital.
Only a month earlier, the Lincolnshire Partnership Trust had adopted a new policy of having patients interviewed to assess whether they would be better cared for in hospital or in their home.
Louth district coroner Stuart Fisher said: "I believe Dr Varley's death was contributed to by the neglect of local health professionals."
He said there had been substantial or gross failure in basic health treatment, and because of those conclusions did not record a verdict.
However, the coroner confirmed the case was closed.
After taking the overdose on February 20 Dr Varley was admitted to hospital and the next day assessed by nurses who said he did not need to be admitted and could go home.
A week later, on February 28, at 9.15am his wife Judith phoned the psychiatric team, but the nurses did not pick up the request until nearly 11am when they offered to visit him at Girsby. By the time they went out to him, he had shot himself.
Prof Elemer Szabadi, of Queen's Medical Centre, Nottingham, said: "Dr Varley should have been admitted to hospital for observation and treatment for severe depressive episodes.
"I am flabbergasted there were a number of opportunities when this admission to hospital could have been arranged.
"The fact they were missed reflects badly on the service and poor communications between clinicians."
The consultant in charge of Cambridge University don and father-of-two Dr Varley, Dr Michael Cutczi, said he would have admitted him but he was on leave throughout February.
Instead, the patient was under a locum doctor who recommended a higher dose of medication.
Dr Varley, a highly intelligent man with a PhD, became acutely depressed in 2000 following a panic attack over the use of a piece of farming equipment.
Widow Judith Varley said she was satisfied with the coroner's conclusions.
Health bosses say this was a 'one-off' situation. A trust spokesman said: "The outcome of the inquest is obviously of concern and we will be carrying out a full investigation of the circumstances of Mr Varley's care."
Chris Slavin, chief executive of Lincolnshire Partnership Trust said: "We express our sincere condolences to the family and friends of Mr Varley. A full report on the outcome of this investigation will be received for consideration by the Trust Board as soon as it has been completed.
"The Trust has an excellent record of care delivery and this is a regrettable and unfortunate isolated incident."