NHS bosses have apologised after a much-loved dad took his own life just days after an “inadequate” medical assessment.

Farmer Stuart Ridley, 39 of Blencogo, Wigton, was found dead at his home on the afternoon of September 20, 2017.

The death of the father-of-two was the subject of an inquest at The Coroner’s Court in Cockermouth.

Despite medication and help from counsellors and doctors, a combination of trauma, imprisonment and debts of £130,000 the proud farmer suffered from serious mental health problems.

Mr Ridley had been assessed at Carlisle’s Carleton Clinic on September 5 by clinician Jane Wheatley and had been determined as being a low to moderate risk to himself, despite detailing a method of suicide in the appointment with Miss Wheatley, the hearing heard.

The assessment has since been the subject of a SIRI (Serious Incidents that Require Investigation) report by the Cumbria Partnership NHS Foundation Trust.

It concluded that the assessment carried out on Mr Ridley in the days leading to his death was “inadequate”, it was found that it was incorrectly documented, that he was enrolled onto the wrong treatment programme as a result, and that a letter sent to him from First Step - which his family says was not received - was not followed up.

The author of the report - Dallan McGleenan - described these factors as “missed opportunities to intervene”.

However, he said that it would be hard to determine whether the factors had directly led to Mr Ridley’s death.

It was found at the time of death that there was no sertraline – the drug used to try and counter his mental health problems - in his blood.

The coroner, Kirsty Gomersal, said that this indicated that Mr Ridley had stopped taking his medication, unknown to his family, some time before his death.

His aunt, Margaret Joyce, was the last person to see Mr Ridley alive.

“He was in low spirits, but he was carrying out the normal tasks he did,” she told the inquest.

“He was waiting for contractors to come, but they were late. They were supposed to come at 4.30pm and they came at 8.45pm.”

She then described what happened the following morning.

“I had seen Stuart between 8.30am and 8.50am. He was certainly distressed.

“He was staring into space. He had been like that for some time.”

Later in the day, a neighbour of the Ridley’s noticed something wasn’t quite right.

Mr Ridley’s wife, Gina, who he married in 2004, also gave evidence.

“I met him at 16 and we were together ever since. He was a kind person, he worked hard. He loved his farming, he loved his family,” she said.

“He had times when he was low, but he didn’t show it to the outside world. He worked long hours, he liked everything to be just right. He made sure his animals were looked after. He knew everybody.

“He had lots of friends, he had a big group of friends.”

Mr Ridley was involved in an incident in his younger years that hit him hard, the coroner was told.

Mrs Ridley added: “Stuart was involved in a serious car accident when he was younger. He went to prison.”

The collision Mrs Ridley described was in June 1997, a fatal crash which saw Mr Ridley as the driver while three of his friends died. Mr Ridley who was aged 20 at the time, was later sentenced to a four- year youth custody sentence – which was later cut to 30 months following an appeal - for causing death by careless driving while under the influence of drink.

According to Mrs Ridley, Stuart’s farming was a coping mechanism for the ordeal he had gone through.

“I think Stuart worked so he didn’t have to think about it. As the years went on, we got married, we had children, we looked forward to holidays.

“He never talked about it, he didn’t want the children to know about it. It was never talked about. We had family days out on Sunday. He wasn’t a big drinker, he went out once a year at Christmas.

Mrs Ridley recalled a conversation she had with her husband prior to his death.

“He told me ‘what is the point in all this’, I said ‘what do you mean?’, he said ‘the circle of life’.

“I said ‘me and the children’.”

It was just over a month before Mr Ridley died that his wife really began to worry.

“On a Sunday we usually would go and have some lunch somewhere. But on Sunday morning five weeks before he died, he said he should take himself to the clinic.

“He said ‘I should be at the clinic’. I said, ‘see how you are later today, we will go out’ I knew fresh air made him feel better.

“He did [feel better], but he was always the macho man. They don’t tell you everything.”

The Coroner was told that the care Mr Ridley received in 2016 was praised by his family and led to him feeling better again. But as the debts mounted from spending money on the farm, his mental health started to worsen.

Mrs Ridley added: “He told me he had some debt and that he needed some tractor tyres that were £3,000 that he couldn’t afford to pay.

“I said we will sell the hot tub. He got worse, he was having hot sweats, he said he was getting nervous driving the tractor across the road.

“He worked with his friend. He wanted somebody there with him. He was falling asleep on the floor in the living room.

“But he was content getting up and feeding his animals.”

Mr Ridley’s physical and mental health continued to worsen, with sickness, diarrhoea, hot sweats and tiredness continuing, the inquest was told.

Mrs Joyce said: “Stuart wasn’t going out to work, he wasn’t bringing any money in. Gina was worried about meeting the bills.

“Stuart said he had about £25,000 of debt. Gina wanted to find out the extremity and extent of it. We had a meeting with him and it quickly creeped up.

“It was around £130,000.”

His family set up a plan for Mr Ridley to follow and it was thought that the financial problem was in hand.

The coroner ruled that Mr Ridley was a much-loved father, whose loss will be sorely missed by his family and wider community. She added that his family did all that they could to save to save him and that they should feel no guilt.

She noted that Mr Ridley had a history of depression, dating back to 2002. It was also noted that the fact that no sertraline was found in his body at the time of death, meaning that it was probable that Mr Ridley had stopped taking his anti-depressants some time before his death.

The coroner explained that following successful treatment in 2016 that he got better and was making positive steps towards improving his mental health.

Mr Ridley’s death also came as a great surprise to his family, added the coroner. She ruled that the assessment carried out on Mr Ridley by Jane Wheatley was inadequate.

She also said that the steps taken by the Cumbria Partnership NHS Foundation Trust in the aftermath of Mr Ridley’s death, satisfied her that the risk of the same thing happening to another patient were greatly reduced.

The long history of mental health problems stemmed from the crash in 1997, said the coroner. She ruled that, on the balance of probabilities, that due to the fact there was no-one else on the farm at the time, that Mr Ridley did intend to end his own life.