A WINCHESTER man who jumped from the roof of a multi-storey car park was "technically" not allowed out of his psychiatric unit on the day he died, an inquest heard.

Carl Lewis, born David Wyn Roberts, plummeted to the pavement at the entrance of the Education Centre at the Royal Hampshire County Hospital on April 16 last year.

The 42-year-old was a patient at Melbury Lodge - a treatment centre for the mentally ill - when he fell some 50 feet, smashing his head against the floor and fracturing ribs on both sides of his body.

The hearing was told Mr Lewis still had a pulse when doctors passing by first tried to resuscitate him, despite the pooling blood.

Though he had gone out on daily walks in the days leading to his death, Dr Guy Powell, consultant psychiatrist at Melbury Lodge, run by Southern Health NHS Foundation Trust, said: "Technically he should never have been allowed out of the hospital".

He said a decision had been made by health officials the day before that, because Mr Lewis had refused to take his medication, they chose to formally detain him - paperwork which never reached the nurses who allowed him to walk out.

"He was being detained not because he was dangerous but because he wasn't taking his tablets," he said. "He had been going out of the hospital on regular occasions. It would have been unreasonable to stop him from going out. We cannot gratuitously deny people liberty."

Charge nurse Keith Waite said the necessary paperwork detaining Mr Lewis, under section 2 of the Mental Health Act, was not done "for some reason".

He also said he wasn't "unduly concerned" that Mr Lewis had not returned back at 10:45am as agreed.

It wasn't until he received a phone call from the hospital telling him Mr Lewis had died that he informed senior staff.

Dr Sanjay Jogai, consultant pathologist, told the jury Mr Lewis died from multiple fractures to the skull as a result of a significant fall.

Police officers found his blue Berghaus rucksack on the roof of the car park which contained a cheque book, his passport and some tobacco.

DC Kevin Lyle of Hampshire Constabulary said he investigated the scene and the route from Melbury Lodge but found no note, no recorded CCTV nor any witnesses who saw him before or during the fall.

Community team consultant psychiatrist Dr Stefan Gleeson said Mr Lewis willingly moved to Melbury Lodge from York House, Worthy Road, in the February because he said he had been hearing voices.

"He agreed he wasn't well and there was a limit to how much more we could support him in the community and it was decided he would come to the hospital," Dr Gleeson said. "He clearly was feeling hopeless about life, felt he was drifting. He denied he wanted to end his life. When he was better he felt he didn't need medication."

Dr Gleeson also said Mr Lewis took several overdoses over the space of two years while at York House, but he did not think it was an actual suicide attempt and merely Mr Lewis's way of coping with loneliness by "blanking out".

His father, mechanical engineer Dr Albert Roberts, wept momentarily as he swore in to give evidence.

He told the hearing Mr Lewis's illness started during his second year of university in Guildford, where he was studying mathematics and computing. He said he began to become withdrawn and show signs of self-neglect, to such a point university staff suggested Carl take a break and return to his studies later in the year.

The jury of four women and seven men returned a narrative verdict by a majority of nine to two.

A spokesperson for Southern Health NHS Foundation Trust said: “Following the conclusion, our thoughts continue to be with the family and friends of Mr Lewis at this difficult time. We had been working with Mr Lewis for a number of years and he was well known to many of our staff. Mr Lewis would often present to our teams informally when he felt he couldn’t manage his condition and our staff were familiar with his routines and often tried to accommodate these as part of his recovery.

“It is vital that our organisation learns from this incident. As a result of this case we have already put in a place a number of key changes which include:

* A new system in place to ensure the correct paper work is completed and sign off has taken place before any patient is granted leave;

* Improvements to paper work which include larger areas for clinicians to record more detailed information about a patients mental state for leave requests and the colour coding of specific forms to enable staff to access key information more efficiently.

“With hindsight it is clear these improvements would not have prevented the tragic outcome. Mr Lewis was not behaving in a way that would cause concern from the professionals supporting him, and following an assessment would very likely have been granted leave, which was a regular part of his routine and important to his recovery.

“We fully accept the coroner’s conclusion, which supports our own internal findings. We are confident that the changes we have made mean our staff will be better able to view a patient’s journey through our services and asses their current state of health when granting leave.”