The Black Country Mental Health Trust is investigating a man’s suicide

The Black Country Integrated Care Board confirmed there was a 48-page report on the incident.

Several referrals were made for Mr Wall to work over a period of time, including some from Sandwell General Hospital, the BBC understands.

A referral in August 2023 was dismissed by emergency mental health services.

There was a further referral in October of the same year, then in January 2024 a watch team was contacted but found no risk.

The Black Country coroner confirmed that a pathologist had given Wall’s cause of death as organ failure caused by a lack of oxygen supply.

He also stated that chronic alcohol abuse and depression were contributing factors.

Black Country Healthcare NHS Foundation Trust said: “Our thoughts are with Mr Wall’s family following his tragic death.

“We are currently carrying out a detailed review of the incident and a report together with any potential associated learning will be submitted to the coroner and the Black Country Integrated Care Board in due course.”

It is the latest incident at the trust, where doctors previously held a vote of no confidence in the chief executive.

The BBC has learned that the Care Quality Commission (CQC) is investigating problems at Walsall’s Dorothy Pattison Hospital, which also deals with mental health patients.

A staff governor recently resigned after the Black Country trust suffered one of the worst deteriorations in its NHS staff survey of any part of England.