The day before a 'severely' depressed young man killed himself by jumping off a bridge his doctor was not available to see him, an inquest heard.
Matthew Lovell's father telephoned the day hospital where his son was an out-patient because he was concerned about his behaviour.
The 26-year-old, of Grove Road, Tring died from his injuries after jumping from the Ridgeway Bridge over the A41 close to the Tring turn-off on June 28, 2006.
Mr Lovell told a nurse at Cornerstone Day Hospital in Aylesbury that Matthew had been low and had been staying in bed a lot.
He had also tried to store up some tablets and had attempted to swallow some tissues.
Despite this Mr Lovell was told Matthew's doctor could not see him because he was on a course. Instead it was arranged that Matthew should visit the following day.
Matthew's care co-ordinator, community psychiatric nurse Ameenah Sheikmamode, was also not told by medical staff about Mr Lovell's concerns.
During an inquest into Matthew's death held at Hatfield on Wednesday, June 6, she told Hertfordshire coroner Edward Thomas: "I would have liked to have known."
Mr Thomas replied: "Because you then presumably would have formed your own decision and decided if you needed a risk assessment."
He said he was 'saddened' to hear that Ms Sheikmamode had not been informed of concerns for Matthew and said he would be writing to Oxfordshire and Buckinghamshire NHS Trust about this.
Counsellor Chloe Carter, who saw Matthew the day before his death, told the court: "I knew that Matthew's father was trying to contact the hospital and I felt that was an important thing for him to be doing.
"From what I had seen I was expecting Matthew to probably be admitted or for there to be some other tighter clinical supervision."
She added: "I asked him what he thought would happen if he had to go into hospital again. He said he didn't think he could cope in hospital.
"He was very very scared and frightened."
On two occasions in March Matthew tried to over-dose on drugs.
He was admitted to the Tindal Centre in Aylesbury and after being discharged was a day patient at Cornerstone. Both centres are for the treatment of mental illness.
Matthew was also on anti-depressant medication.
On the day of his death he had told his mother he was going for a bike ride.
Joy Dyson was driving along the A41 at about 1pm and saw a figure fall from the bridge. She stayed with Matthew until emergency services arrived.
Mr Thomas said: "She stayed with him and did what she could for him. I think she should be applauded."
Matthew, who was taken to Hemel Hempstead Hospital, had brain injuries, fractures to his legs, injuries to his pelvis and extensive bleeding internally.
He suffered two cardiac arrests and on the second occasion doctors were unable to revive him.
Mr Thomas recorded a verdict that Matthew took his own life whilst suffering from clinical depression.
He said: "What that means is he had an illness. He came from a supportive family, it wasn't a reaction to a crisis. He had an illness."
He added: "Life is often a lot of what ifs. It is not for me to be judgmental. It is easy for me sitting here and analysing the situation to say what if or this should have been.
"My feeling is that the care co-ordinator has an extremely important role in assessing people in relation to helping them to come to terms with their illness, to make the best possible life they can with the condition they have and therefore I was saddened to hear that on June 27 the care co-ordinator was not informed about the situation.
"I feel that if she had been informed having carried out a risk assessment of the concerns that she might have been able to co-ordinate a response to that.
"Bearing in mind that the most devastating thing for Matthew would have been for him to go back into hospital I'm not sure what the result of that response would have been.
"I'm not sure if it would have changed the course of events but none the less it didn't happen and I think it would have been helpful.
"I'm going to be writing to the trust to express that.
"I think it is a great tragedy that the care co-ordinator was not informed."
He added: "If the family had had the opportunity of speaking to the care co-ordinator there might have been something different but I'm not sure if the final outcome would have been different.
"I feel desperately sorry for him (Matthew) and his family."
Family thank 'the courage' of the motorist who tried to help their son
The parents of Matthew Lovell have paid tribute to the motorist who stopped to help their son after he jumped from a bridge over the A41 near Tring.
Joy Dyson of Aston Clinton saw a figure fall from the Ridgeway Bridge as she drove along the bypass in June last year.
She stopped to help Matthew who was lying in the central reservation of the road.
Matthew's dad Brian Lovell said: "I would like to pay tribute to the courage of Mrs Dyson.
"Not only did Joy witness Matthew's fall from the bridge but she had the presence of mind to stop her car and contact the emergency services.
"This brave lady, at great risk to herself, then went to Matthew in the central reservation.
"She held his hand and comforted him whilst guiding the paramedics and police to the scene.
"She did all this while traffic was still speeding by."
Speaking after the inquest into Matthew's death, Mr Lovell, went on to say: "The love my wife Carol and I have for our only son Matthew is unconditional and we remain immensely proud of him.
"Mr Thomas, the coroner, acknowledged what a talented and well respected young man Matthew was.
"The family considers that the coroner's verdict is an accurate reflection of Matthew's state of mind in June 2006, in that he was suffering from an illness."