Mike Petter's resigned from the trust, which covers Hampshire and Dorset, as a report says it's still failing to protect mental health patients.
Inquest Rules Lake Death An Accident
A coroner's ruled that the death of a charity shop worker whose body was left floating in a shallow boating lake by the emergency services was an accident.
But David Horsley, coroner for Portsmouth and South East Hampshire, called on the fire, police and ambulance services to improve their training to ensure the right decision is made in future drowning cases following the death of Simon Burgess.
His father, David Burgess said after the hearing:
''We will never know if Simon could have been saved, if he had been pulled from the water as soon as the emergency services arrived on the scene or if it was already too late for him.
''When a loved one is involved in an incident like this you can only hope that everything possible is done to save them regardless of how small the chances of success are.
''We appreciate that the emergency services operate in difficult situations where split second decisions are required but it is also clear that they are often hindered by rules and procedures that attempt to eliminate all risk when by its very nature effective emergency work will always have some risk.
''We hope lessons are learnt and as a result someone is saved in the future Simon's death would not have been in vain.''
The Portsmouth inquest heard that Mr Burgess was seen to drop a bag into Walpole Park lake and to enter the water to retrieve it shortly after 12pm on March 10 year.
The 41-year-old is then believed to have suffered an epileptic fit and fallen unconscious in the water.
A member of the public dialled 999 at 12.15pm and at 12.17pm Hampshire Fire and Rescue Service scrambled two fire appliances and a specialist water rescue unit.
The fire appliances arrived at 12.20pm and by 12.22pm Watch Manager Tony Nicholls had arrived and talked to members of the public about the situation.
The inquest heard that, at first, Mr Nicholls could not see Mr Burgess whose body had floated up to 25 metres away.
When he had sighted it, he took the decision, which was agreed by his crew, that Mr Burgess had died.
Adhering to force policy not to enter water more than ''half a boot'' deep unless in a life-critical situation, he ordered his crew not to retrieve the body and to wait for the water rescue team, based at Fareham, which arrived at 12.31pm.
These specially-trained officers were equipped to enter water with flotation devices to retrieve the body.
The inquest heard that Pc Tony Jones, of Hampshire police, had volunteered to enter the water to retrieve Mr Burgess but had been ordered not to by Mr Nicholls and his own control room.
Paramedic Robert Wallace also suggested he should enter the water but did not after Mr Nicholls asked him where his equipment was, the inquest heard.
The body of Mr Burgess was eventually retrieved from the water at 12.52pm and was taken to Queen Alexandra Hospital in Portsmouth where he was pronounced dead at 1.42pm.
Pathologist Brett Lockyer told the hearing that a person cannot normally survive after being immersed unconscious after between five and seven minutes but added that under certain circumstances, including in icy conditions, this could be between 20 minutes and an hour.
Mr Horsley said that he could not be certain that the delay in the recovery of the body had contributed to his death.
He said: ''In this case the delay in arrival of the specialist team has not been a significant factor in this tragic death.''
He called on the three emergency services to re-examine their training in appropriate resuscitation times after immersion in water and to work together to come up with new joint protocols.
He said: ''I am going to request they get together and re-examine the protocols jointly so the protocols can give the best possible guidance for situations like this where a life may hang in the balance.''
Temporary Assistant Chief Officer Andrew Bowers, of Hampshire Fire and Rescue Service, said that his officers made the decision on the scene that Mr Burgess was already dead.
He said that the force policy did not forbid the firefighters from entering the water if they were carrying out a life-saving operation.
He said that health and safety regulations allowed for officers to take risks when a life could be saved.
''It was a decision made at the time, based on the evidence that Watch Manager Nicholls could gather, that it was a matter of recovery.
''It clearly wasn't a health and safety related issue, it was purely about the pragmatic decision that Mr Burgess was unfortunately already deceased.
''Where there is a life to be saved we will take great risks to save a save-able life.''
''They made a decision based on the view the unfortunate Mr Burgess was already deceased and it was more appropriate to wait for the water recovery unit to recover the body.''
However Mr Bowers did accept that there should have been better communication between the emergency services at the scene and clearer protocols on how long after a body was found in water that resuscitation was still a viable option.
A Hampshire Fire and Rescue Service spokeswoman said after the inquest:
''This was a tragic incident and our thoughts remain with the family and friends of Mr Burgess at this difficult time.
''The decisions taken at the Walpole Lake incident had nothing to do with health and safety or the depth of the water.
''Our officers and staff made an informed assessment and judgment based on the circumstances they faced.
''On arrival at the scene, the officer and crews saw a body face down and submerged in the water - who we now know to be Mr Simon Burgess.
''That person was unresponsive and showing no visible signs of life.
''Based on this assessment, they prepared for the arrival of one of the service's specialist water rescue unit to undertake a dignified retrieval of the individual from the water.
''Our officers and staff clearly stated, that if they saw any signs of life and the individual could be saved, they would have gone in to the water and followed rescue procedures.
''Our officers and crews followed our service policy which is in line with national guidance.
''Hampshire Fire and Rescue Service fully supports the decisions and actions of its officers and crews on that day.
''After this incident and subsequent internal debrief, we reviewed our water rescue policy and made changes based on our findings. These changes are in response to identified gaps in the existing policy and suggested changes by our staff.''
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