Lord Monson's son Rupert Green failed by NHS
A peer's son who took his own life was let down by an NHS trust, a coroner has ruled.
Rupert Green, a user of strong cannabis and son of hereditary peer Lord Monson, killed himself in January 2017 after displaying symptoms of psychosis.
Sitting in Woking, Surrey, assistant coroner Anna Crawford said there had been a failure on the part of Surrey and Borders NHS Trust.
The trust said it was "deeply sorry" for 21-year-old Mr Green's death.
The inquest heard he had been under the care of the Early Intervention in Psychosis Team, a branch of the Surrey trust, since 2016.
'Son of God'
On 15 January 2017, Mr Green was taken by his mother to an out-of-hours service for people with mental health issues.
He was displaying acute psychotic symptoms, "stating he was the son of God", and threatening to kill himself if not believed, the inquest heard.
A mental health nurse was said to be "very concerned about him" and asked her colleagues at the trust's Home Treatment Team (HTT) to carry out an assessment, but they refused the referral.
Instead he was seen for a planned review the following day.
He continued to display signs of psychosis but stopped threatening to kill himself. On 18 January he began the threats again, and told his mother there "would be blood on her hands" if she did not believe him.
He was found dead later that day in the family's garden.
Concluding Friday's inquest hearing, Ms Crawford said there had been "a failure on the part of the HTT to assess and care for Rupert during the period of 15-18 January 2017", but there was not a sufficient connection "between that failure and Rupert's death" to conclude there had been neglect.
Justin Wilson, the trust's chief medical officer, said after the hearing: "Our serious investigation into the care and treatment provided to Rupert has shown the communication between our Safe Haven service and Home Treatment Team was not clear and requires improvement.
"There was a missed opportunity for more intensive support from our Home Treatment Team and we have worked closely with the services involved to make positive changes."
In 2017, Nicholas Monson told the BBC his son, who was heir to the family's Burton estate in Lincolnshire, had suffered from psychosis as a result of an addiction to skunk - a strong form of cannabis.
The peer has campaigned for the legalisation of milder forms of cannabis and tougher penalties for those dealing the skunk strain.
In 2012, his son Alexander Monson, 28, died in police custody in Mombasa, Kenya.