A CORONER slammed health workers for not doing enough to prevent a depressed ex-convict hurling himself in front of a train.

Peter Bedford accused psychiatric and bail hostel staff of missing a chance to help after hearing a vital report was still lying on a nurse’s desk when 50-year-old Stuart Thorne killed himself at Reading West station last year.

Mr Thorne, who had battled drug and alcohol abuse and homelessness, signed out of St Leonard’s hostel in Southcote Road at 11.29am on Saturday, January 26, and 24 minutes later jumped in front of a Paddington-Bedwyn First Great Western train.

Recording a narrative verdict at yesterday’s Reading inquest, Berkshire coroner Mr Bedford acknowledged Mr Thorne refused to take medication or attend meetings with forensic community psychiatric nurse Andy Flashman, who told the court: “I tried the best I could with the information I had. It’s quite a challenge to form a care plan without his involvement.”

But Mr Bedford said: “Key factors were a lack of proactive information gathering by mental health professionals and not involving Mr Thorne in wellbeing support that may have helped him through his period of crisis.”

He was scathing of hostel staff for not reporting Mr Thorne’s mood deterioration or refusal to take medication to Mr Flashman during the four months he spent there after leaving Bullingdon Prison in September 2012.

He added: “The opportunity to escalate to the mental health team and seek assistance was not taken and that is another missed opportunity.”

But key hostel worker Carolyn Curtis defended her decision, and insisted Mr Thorne’s anxiety was triggered by the threat of becoming homeless again and the failure to find him private accommodation.

She said: “I think he was fearful for a number of reasons, homelessness in particular. But I think I was afraid he would start drinking again and re-offend and that being homeless would be the trigger.”

Mr Bedford conceded that the threat of homelessness contributed to Mr Thorne’s anxiety but said two previous suicide attempts - including leaping off an Oxford multi-storey car park in 2010 - should have meant the concerns were flagged up.

He said Mr Flashman could have been done more to contact Mr Thorne’s GP when he refused to attend meetings, did not update his records on Berkshire Healthcare Trust’s computer system or act on a vital report.

He added: “I acknowledge the frustration of getting the information but when it was made available it then sat on Mr Flashman’s desk under other papers.”

*Mr Bedford also criticised the Trust in 2010 when 24-year-old Prospect Park Hospital patient Eva Dobraszczyk killed herself after slipping away from her carer during a supervised shopping trip.