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17 April 2019, 18:39 | Updated: 17 April 2019, 18:45
An inquest has heard how a mentally-ill man killed his wife and then himself, just hours after they were turned away from the A&E department at Ipswich Hospital, where they had tried to get help.
32 year old Thomas Kemp and his wife, 31 year old Katherine, died in August last year, after Katherine called 999 in the early hours one morning saying Thomas was threatening to kill himself.
Officers arrived at their falt in Ipswich and gave them a lift to Ipswich Hospital, but the couple were turned away by the mental health crisis team who mistakenly believed the episode was about Mr Kemp's anxiety over the size of his penis.
Mr Kemp had previously been assessed as suffering from anxiety, body dysmorphic ideas and paranoid delusions.
He was due to meet with the psychiatric liaison team later that morning.
Suffolk area coroner Jacqueline Devonish said that the failure to consider alternatives to discharge from hospital was a "missed opportunity to have done something effective to prevent these deaths".
Recording narrative conclusions, she said that Mr Kemp stabbed his wife to death during a psychotic episode when Mrs Kemp tried to prevent him from harming himself with a knife.
Mr Kemp cut himself then fell from a window and bled to death.
She said the deaths were contributed to by Mr Kemp's "non-compliance with prescribed medication" and the "failure of the crisis response team to see (Mrs Kemp) and her husband and undertake an assessment" when they went to hospital earlier that morning.
The coroner added: "Thomas loved Katherine and wouldn't have knowingly hurt her."
A&E receptionist Mandy Mckenzie previously told the hearing that when the Kemps arrived at the department Mrs Kemp told her "please can you help, he has knives and is going to harm himself".
"Mrs Kemp was very distressed and tearful and kept asking for help," she said.
"Mr Kemp made no eye contact and kept looking at the desk.
"Mrs Kemp kept holding onto his arm."
Triage nurse Maria Tabar, who said she assessed Mr Kemp as high risk then told the crisis team, said during her evidence that the crisis team told her: "You know the problem? Suicidal thoughts are not the problem, it was his manhood."
Coroner Ms Devonish said: "Her evidence was they were just laughing about Thomas.
"She was surprised and couldn't understand."
In a statement read by barrister Jonathan Metzer after the conclusions were read out, the family of Mr Kemp said: "Both Thomas and Katherine reached out for help and they were discharged."
They said the pair were "failed", adding: "We don't want to see the pain our family are experiencing repeated."
Diane Hull, chief nurse of Norfolk and Suffolk NHS Foundation Trust (NSFT), said after the hearing that the trust had commissioned a review and identified areas for improvement, including team working and communications.
"There is an absolute need to learn what went wrong and why, so that services can be improved and, most importantly, prevent another family suffering what Mr and Mrs Kemp's families have been through," she said.