Paragraphs 10 & 11 read: "He was given anti-depressants, only allowed to leave on escorted visits and monitored every 10 minutes, for his own safety."
"But on the day before he died, mental health staff ruled Mr Boss's condition had improved and he could be allowed out on short, unescorted visits."
Teacher killed himself after leaving ward for cigaretteFriday, June 19, 2009, 10:01
PROPER procedures were not followed before a Nottingham teacher hanged himself in hospital, a coroner has said.
Adam Boss was found hanged in a toilet at the Queen's Medical Centre, where he was being treated in a Notts Healthcare Trust-run psychiatric ward for depression and anxiety.
The 36-year-old, from Carrington, was allowed to leave the ward for a cigarette on November 12, but his name was not written on a board to show he had left.
Staff should have passed the information to a senior nurse, to make sure he was back before a 15-minute time limit.
But an inquest in Nottingham was told they did not notice Mr Boss had not returned until 25 to 35 minutes after he left.
Minutes later, the English teacher was found hanged in a toilet.
He had been acting deputy head teacher of Greenwood Dale School in Sneinton before moving to Elliott Durham School in Mapperley.
A father-of-two, he was admitted to hospital voluntarily, suffering from depression and anxiety.
He had told a GP he had detailed plans to kill himself.
He was given anti-depressants, only allowed to leave on escorted visits and monitored every 10 minutes, for his own safety.
But on the day before he died, mental health staff ruled Mr Boss's condition had improved and he could be allowed out on short, unescorted visits.
Psychiatrist Dr Nick Mepham said: "He was happy with that. He was absolutely confident he could keep himself safe.
"When asked about his level of impulsiveness, he said he was not an impulsive person."
The psychiatric wards at the QMC are not run by the Nottingham University Hospitals Trust, which runs the rest of the hospital..
Recording a verdict of suicide, Notts Coroner Dr Nigel Chapman said Mr Boss was "certainly off the ward for longer than 15 minutes" before staff looked for him.
He said: "His name was not on the whiteboard and neither were the proper procedures followed as to allowing him off the ward and not knowing how long he was off the ward."
"He has gone outside for a cigarette and then, for whatever reason, we often don't find reasons, he has gone into that toilet and done an act to take his own life."
Mr Boss's father, Gerald, told the hearing he could "only speculate" why his son took his own life.
He said: "I know he had a massive fear that he wouldn't recover. He felt he was letting his family down.
"He loved teaching and he loved working with young people. From the young people's accounts, that regard was reciprocated.
"He had a fine future and a lovely family. He had no obvious reason to do what he did, other than his illness."