The family of a former rugby star are searching for answers after he took his own life a day before he was due to be discharged from hospital.
Nick Köster, a South African who played for Bath and Bristol, died on July 11, 2023, while an in-patient at Priory Hospital in Attleborough, one month after being admitted there.
Norfolk Coroners Court heard Mr Köster left the hospital and was found dead by a member of the public in a wooded area close to the facility. He was aged 34.
During the first day, of the two-day inquest, the family questioned why the father-of-two was not referred to a psychiatrist sooner, with a family history of the mental illness.
Mr Köster's mother was diagnosed with bipolar type two disorder around 12 years ago with several depressive episodes.
'He feared he wouldn't be able to provide for his family'
A statement read out by one of Mr Köster's sisters, Terena, stated: "In October 2022, Nick was on a big high having been on a work trip to America.
"He felt very confident and was excited about his work prospects.
"He'd never voiced concerns about his mental health in the past but in March he began to struggle with it and called me to say he was worried he was heading towards depression.
"Nick had been working very long days and feared he wouldn't be able to provide for his family.
"He informed us of his struggles, including increasing anxiety and insomnia was spiralling.
"On holiday to see me in Copenhagen I'd never seen him looking so sad and he was very insecure in himself which was such a contrast to the Nick I'd known prior to this time."
Family pushed for 'psychiatric evaluation'
As his health continued to decline, Mr Köster sought help from his GP and in April 2023 was referred to Weavers Centre at Hellesdon Hospital by the first response team due to lack of mood, sleep and thoughts of suicide.
In May 2023 Mr Köster was handed over to the Crisis Resolution and Home Treatment team (CRHT).
However with his mental health deteriorating rapidly the family pushed for a more in-depth psychiatric evaluation with his mother's previous history with bipolar disorder.
During a multi-disciplinary team meeting (MDT) Dr Marie Diaz, a consultant psychiatrist at the CRHT at Hellesdon Hospital, said his case was "discussed at length and it was agreed a further assessment with myself was not clinically indicated as he had clear diagnosis of depressive disorder".
The family said it was "desperately disappointed and concerned" with the news as they thought a more thorough investigation was required to ensure treatment plan was right for him.
A statement from the Crisis Care team said it was "satisfied with the assessment and treatment plan for Mr Köster" and that he was dealing with depression and anxiety.
The family sought a meeting with another psychiatrist who provisionally diagnosed him with bipolar disorder.
Admission to Norwich Priory
After a psychotic episode at home Mr Köster was admitted, via the NHS, to Norwich Priory on June 14.
Dr Adrian Lord, medical director at the priory, said Mr Köster's mental health slowly began to get better while there and was given accompanied leave for his daughter's birthday.
He added he was making the improvement needed and was satisfied that "all appropriate care was taken into account" leading up to Mr Köster's proposed discharge date of July 12.
On the day of his death Mr Köster who was at this time allowed unaccompanied leave based on his overall improvement asked to go out to the shops.
The inquest continues.
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