Paragraph 10 reads: "Mental health worker Catherine Staff, based at Hillview Lodge at the Royal United Hospital in Bath, told the inquest Mr Brown was prescribed lorazepam to help him cope with the side effects of increasing the dose of his anti-depressant drug."
"But she said his lorazapam should have been reduced more gradually, rather than being suddenly halved."
THE son of former BBC Points West reporter Peter Brown had his medication reduced two days before he took his own life, an inquest heard.
Friends said Will Brown, 51, became more stressed and agitated when he was told his prescription for a tranquilliser drug would be halved. Days later on September 16 last year, the builder was found hanged in the bedroom of his home in Totterdown.
The inquest at Flax Bourton Coroner's Court heard Mr Brown had suffered from deep depression twice in the 12 months before his death and had battled with the condition since he was a student. He had been due to talk to psychology students at the University of the West of England about depression on the day he died.
In a statement read to the inquest, his father Peter, 83, of Westbury Park, said his son feared mental health workers had "given up on him".
He said his son had told his sister Vicky about his suicidal thoughts and his mother Heather that he "hated himself and had no personality left because of the drugs".
The inquest heard Mr Brown's friend Kate Fraser noticed he was agitated on September 13, when he complained that the mental health crisis team were planning to reduce his support and halve his prescription for lorazepam, a drug used to treat his anxiety and insomnia.
His best friend Stephen Rose told the inquest Mr Brown had told him how he intended to kill himself. Mr Brown told him he thought he was a "hopeless cause as far as the medical profession was concerned".
Mr Rose, who lives in Bishopsworth, told the inquest: "I wish he could have been taken into hospital when there were so many clear signs that there was an intent to harm himself."
Mental health worker Catherine Staff, based at Hillview Lodge at the Royal United Hospital in Bath, told the inquest Mr Brown was prescribed lorazepam to help him cope with the side effects of increasing the dose of his anti-depressant drug.
But she said his lorazapam should have been reduced more gradually, rather than being suddenly halved.
Ms Staff acknowledged that the move was not good practice, adding: "It would have been unhelpful to him and would have increased his distress."
She said visits to Mr Brown from the crisis team were due to be reduced from daily to every other day as part of his management plan.
Ms Staff said Mr Brown was not a suitable candidate for hospital treatment as he was not "extremely disturbed" and may have become frightened and more depressed if he had been admitted on to a mental health ward.
The inquest heard that the Avon and Wiltshire Mental Health Partnership NHS Trust had learnt lessons from Mr Brown's case, which was classed as an unexpected death.
His sister Vicky told the inquest her brother had told members of his crisis team he had bought rope in order to take his own life. She said her brother had tried to commit suicide 31 years ago and told friends and family he wanted to take his life. She questioned why her brother had not been admitted to hospital for care.
Avon coroner Maria Voisin adjourned the inquest until a date to be fixed in July, when more witnesses will be called to give evidence about Mr Brown's care.
Most people who are thinking of taking their own life give warning signs beforehand. These can include becoming depressed or withdrawn, sudden changes in behaviour or mood, and feelings of hopelessness.
If you need help or are concerned about someone, call the Samaritans on 08457 90 90 90.