The report on the inquest of John Blair makes tragic reading.
The father-of-two was desperate for help and admitted himself to the Woodlands mental health unit.
Two days later he was discovered hanging by a belt in his room.
In this day and age, such an appalling tragedy should never have been allowed to happen.
Mr Blair was seen as a high risk of suicide, had made several serious attempts on his life in the past, and been full and frank about this to Woodlands staff.
Yet he was placed on the third lowest suicide watch, namely 15-minute observation rounds, and not monitored more closely, as his grieving family say he should have been.
Mr Blair’s death was the third to occur at Woodlands in the space of 18 months and directly led to the closure of the unit.
The others, that of 34-year-old Susannah Anley, happened in April 2008, and Sergeant Richard Bexhell, in August 2009, just two months before Mr Blair’s suicide.
All three tragedies led to an overhaul of the mental health trust’s policy and a £500,000 revamp of Woodlands.
But questions still remain.
Firstly, how did Mr Blair get hold of the belt? Staff were at odds on how it happened.
Secondly, why did it take the deaths of three human beings for the trust to decide to change things?
THERE are many laws in this country which need a serious overhaul.
None more so than the one affecting dozens of residents in Undercliff.
Way back in 1966 a group of builders started hacking away at the earth underneath the cliff edge to build what would have been by all accounts another sixties architectural disaster.
Within a few years a major landslide decimated the site and scattering tons of earth and debris into neighbouring gardens.
The site is then abandoned for three decades before the next developer comes along and decides to have a go at turning a potential disaster zone into a des-res.
However they managed to get as far as the footings and a few car park bays before it all came tumbling down once again.
Four years later the council decides enough is enough and threatens the developer with a fine, not that a £1,000 penalty would sting many developers into action these days.
It seems this land was unsuitable to build on from the start but half a century later its is left a half-finished eyesore that nobody appears to want.
Even if the site could be completed to plan, the flats would overlook other residents’ homes and the windows would have views of brick walls and mounds of earth.
It is not good enough to allow developers to put a few bricks down and walk away from the job knowing they can come back to it whenever they want.
There are enough architectural eyesores in this town already.