The death of a man is being investigated by a mental health trust after it emerged crisis teams failed to take action despite several referrals.
Heron Wall, 49, took his own life in West Bromwich on 18 February this year.
In the months before his death, it has emerged medics asked specialist mental health teams to support him on a number of occasions but they never did.
The Black Country Healthcare NHS Foundation Trust said a report would be submitted to the coroner in due course.
Several referrals had been made for Mr Wall to the service over a period of time, including some from Sandwell General Hospital, the BBC understands.
A referral in August 2023 was rejected by emergency mental health services.
There was a further referral in October the same year, then in January 2024, an on-call team was contacted but identified no risk.
The Black Country coroner confirmed a pathologist had given Mr Wall’s cause of death as organ failure caused by lack of oxygen supply.
It also stated chronic alcohol abuse and depression were contributory factors.
The Black Country Healthcare NHS Foundation Trust said: “Our thoughts are with Mr Wall’s family following his tragic death.
“We are currently undertaking a detailed review of the incident and a report along with any associated potential learning will be submitted to the coroner and Black Country Integrated Care Board in due course.”
It is the latest incident at the trust, where doctors have previously held a vote of no confidence in the chief executive.
The BBC has learned the Care Quality Commission (CQC) is investigating issues at the Dorothy Pattison Hospital in Walsall, which also looks after mental health patients.
A staff governor has recently resigned after the Black Country trust suffered one of the worst deteriorations in its NHS staff survey of anywhere in England.
The health trust said it continued to work with the CQC to support any requests for information or visits to services.
It also said it needed to improve and it that it has developed plans in partnership with staff to make their experience better, including in relation to health and wellbeing.
Management are continuing to strengthen the relationship with the consultants following a number of successful meetings, it added.
The chair of the Medical Advisory Committee said: “Positive progress has been made and we continue to meet regularly with the board.”
