MENTAL health bosses were last night facing demands to carry out a full review of services after two suicides in three months exposed failing systems.

Oxford Heath, the NHS mental health service for the county, admitted this week to a coroner it should not ignore warnings from other health professionals after Gareth Christian took his own life.

His community mental health nurse had rung the Oxford Health’s Crisis Team about Mr Christian, saying it needed to help him. But it would not because the request had not come from the patient directly.

Head of nursing Susan Haynes told coroner Darren Salter the organisation had now changed its policy and would carry out face-to-face assessments following a referral from any health professional.

But it comes four months after Oxford Health said it had uncovered a similar flaw following the death of Graham Kirtland, 39.

He was only able to make contact with Crisis over “a very bad” telephone line and his death in Greater Leys led to a policy where referrals from GPs would lead to face-to-face assessments.

Last night Oxford East MP Andrew Smith said: “These tragedies have revealed failings in the system which is supposed to support people at risk of suicide.”

He welcomed the changes to the referral procedure, but said: “I think it would be very much in the public interest for the health trust now to hold a comprehensive review of referral arrangements to try and make sure people in need of help do not slip through the net.

“Health professionals do a demanding job working with these patients, who can often be difficult and disturbing, and it is in the interests both of those with acute mental health needs and the public generally that referral procedures are robust and dependable.”

Health Oxford did not comment when asked whether it would now review all of its referral systems to discover any other failings.

Mr Christian’s community mental health nurse Mark Johnson told the coroner that the 31-year-old from Littlemore, who suffered from schizophrenia and had attempted to take his own life three times, had rung him in a desperate state.

Because he was not on duty, Mr Johnson called the Crisis Team but it would not take on the case because it “did not routinely” make contact with patients who had not contacted the mental health organisation directly, he said.

Mr Johnson said: “I stressed clearly and forcefully that I was not in a position to respond, because I was not at work and it is appropriate work for them to take forward.

“Gareth phoning me was him phoning for help – the matter of who he phoned was to me a technicality.”

He added: “It was my expectation they would have made contact with Gareth as a result of my expressing concern about his welfare.”

The Crisis Team said it would hold an internal meeting to decide what to do. In the meantime, Mr Johnson spoke to Mr Christian again and emailed the Crisis Team saying he believed his mental state had improved.

The Crisis Team later emailed to say staff would not visit Mr Christian. He was found dead at his home two days later, on November 14, by police.

Mr Johnson had raised the alarm after being unable to contact his client.

Mrs Haynes told the inquest that the Crisis Team had not taken action because of Mr Johnson’s email.

But she said all referrals made by professionals would in future result in face-to-face contact with the client, which she described as a “clarification” of the rules.

Coroner Darren Salter said he had considered making a recommendation about the Crisis Team’s policy but said “appropriate steps” were now in place.

Mr Salter recorded a verdict that Mr Christian had taken his own life.

County councillor Dr Peter Skolar, the chairman of the Oxfordshire joint health overview and scrutiny committee, said he would discuss the referral systems with Oxford Health at the committee’s next meeting, on Thursday, July 5.

He said: “If this indicates there is a problem in the service we would follow that up with the provider and expect to come up with answers.”

Patrick Taylor, director of mental health charity Oxfordshire Mind, said: “Mental health service users and carers need someone to turn to in a crisis – and a crisis can often happen at evenings and weekends when fewer support services are available.

“If these particular investigations result in changes to make it easier for people to get help then that is to be strongly welcomed.”