FAILINGS have been found in the care of an Amesbury flight test engineer who was found dead near a railway track after going missing from a mental health ward.

Carl Harris, from Amesbury, was pronounced dead on July 8, 2013, after his body was found in undergrowth by railway engineers west of the A303 overbridge at Bapton, near Wylye.

The 43-year-old had gone missing a week earlier from Beechlydene Ward at Fountain Way, Salisbury, where he was being treated as a voluntary patient.

Dr Harris suffered from bipolar disorder and was having his medication reviewed after suffering a relapse in his condition.

Assistant coroner for Wiltshire and Swindon Dr Claire Balsyz returned a narrative verdict last Thursday into his death.

She said: “There were numerous failings in his care. However, I do not find a link between these failings and Carl’s death. I am satisfied they have been addressed appropriately.”

Dr Balsyz told the inquest there had been no justification to detain Dr Harris under the Mental Health Act or stop him from leaving the ward but added there were failures in his assessment and observation and a failure to warn Dr Harris that a torch would be used to check on him whilst he was on the ward, which the inquest heard was not an appropriate way to assess anxiety patients.

She said a true picture of the severity of Dr Harris’s symptoms was not conveyed to doctors as his family was not present or made aware of the meeting.

The inquest heard after the care review Dr Harris asked to leave the ward and a “misunderstanding” with a staff nurse meant Dr Harris left alone rather than with Reverend Bill Smith.

Dr Harris went to Salisbury Railway Station where he bought a ticket to Grateley but CCTV footage showed he had become “agitated” after boarding the wrong train and used a fire extinguisher to break a window before climbing through it.

The medical cause of death was multiple injuries “in keeping with a fall from a fast moving train”.

A spokesman for Avon and Wiltshire Mental Health Partnership NHS Trust, who run services at Fountain Way, said: “We would like to offer our sincere condolences to the family of Carl Harris.

“The safety of our service users and staff is taken seriously and following any incident we conduct our own internal investigation to see if any improvements can be made.

“Families are involved in the care of our service users and informal patients now agree a written leave plan on admission. Communications between ward staff have been reviewed.”