A SUICIDAL takeaway worker was left alone at Hereford County Hospital moments before leaving the premises to step in front of a train last August, an inquest heard yesterday.

Police, paramedics and hospital staff all attempted to explain why Luftar Coku, who had been detained earlier that afternoon under the Mental Health Act for his own safety, was left unsupervised.

PC Stephen Adams, now retired, told nursing staff "if he goes, he goes", before leaving the 39-year-old in their care, the inquest heard.

On August 1 2013, Mr Coku was escorted by police to the hospital after he told his friends he intended to throw himself in front of a train.

A lapse during the handover to nursing staff meant that he was left alone in the Accident and Emergency ward's relatives room. 

"Frankly the A and E department is not safe - it can't be sealed off," said Jules Walton, a consultant in emergency medicine based at the A and E department, when asked why the department was not considered a 'designated place of safety' for those detained under section 136 of the Mental Health Act.

"We can't physically watch every person, every second - therefore it is not deemed to be a place of safety."

By law, the officers were obligated to deliver Mr Coku to a 'place of safety' before handing him over to medical staff.

Since 2011, Dr Walton added, A and E at Hereford had not held that designation, and officers needed to stay with the patient to ensure he was safe.

At the same time, the corridor nurse who received Mr Coku, Fiona Goodarzi, said she had no idea the patient had been detained, and that she didn't know what section 136 was.

After a brief physical assessment PC Adams left Mr Coku with the nursing staff.

Mrs Goodarzi said: "I asked 'What happens if he goes?'

"He said 'if he goes he goes', and added that it wouldn't be him who would be called out to look as he was finishing his shift."

Minutes later Mr Coku carried out his threat, crossing the hospital car park to the nearby railway line.

Despite the work of paramedics he died a week later at Queen Elizabeth hospital in Birmingham.

The 39-year-old was a very caring man, a passionate Manchester United fan who lived for his fiancée, the inquest heard.

But his best friend, Erkan Varli, who worked alongside him at Flames in Leominster, said he noticed a dramatic change in Mr Coku's behaviour after a trip to see family in Albania in June 2013.

When he returned, he began taking anti-depressants, but the situation continued to worsen.

"Sometimes he would say his brain wasn't working, and he would have five-second mental blocks," Mr Varli told the inquest.

Previously Mr Coku had incurred gambling debts into the thousands, but had always been able to pay them off.

One morning in July, he told his fiancée that his mother had appeared to him in a dream and the couple had to go to Albania to get married - then later Mr Coku was seen burning a handkerchief given to him by his mother in the garden.

On July 31 Mr Coku packed a suitcase and told his fiancée he was leaving, and, distraught, she called his friends.

The following day, Mr Coku broke down, crying in the middle of the street and telling Mr Varli he was going to step in front of a train.

Mr Varli said: "That's when I thought it was a good idea to call the police.

"But I never thought he would kill himself - when he cut his finger, he was like a baby."

PC Damian Sowery was first to attend, arriving at Etnam Street in Leominster at around 2.30pm.

He escorted a now silent Mr Coku to his police car.

PC Sowery said: "I told him he needed to go to the hospital and he said 'Yes, take me there'.

"He said he wanted to kill himself and I was concerned he may be successful."

Mr Coku was detained by PC Adams under section 136 of the Mental Health Act, although - deemed to be calm and compliant - was taken, with a police escort, to A and E by paramedic Jeremy Daw in an ambulance vehicle.

Mr Daw told the inquest that when he handed over the patient at A and E, he made it clear that Mr Coku had been detained under section 136 - and therefore should be supervised at all times if he isn't deemed to be in a place of safety.

However, in the hour that followed Mr Coku was left unsupervised, and train driver Philip Barnes described how, before stepping into its path, Mr Coku looked down the tracks, directly at the train.

"Incidents like this are taken incredibly seriously," said Dr Walton, who added that extensive training had since gone on to educate staff about accepting patients detained under the Mental Health Act.

"This is a catastrophic outcome for which we are incredibly sorry."

The inquest at Hereford Town Hall continues.