A mental health trust has been criticised for failing to prevent a patient killing his wife and then taking his own life.
Thomas and Katherine Kemp were found dead in Ipswich on 6 August.
An inquest heard Mrs Kemp, 31, was found with 28 knife wounds at the flat she shared with her husband, 32.
Ipswich coroner Jacqueline Devonish said the refusal to offer Mr Kemp a bed or assessment was a “missed opportunity” to prevent their deaths.
She criticised Norfolk and Suffolk NHS Foundation Trust (NSFT)’s crisis team for not intervening, after the couple had visited hospital in the early hours of 6 August.
‘Desperately reached out’
University worker Mr Kemp was found outside the communal entrance to the block of flats in Siloam Place, where he was believed to have fallen from the window, and the couple were pronounced dead shortly after 09:30.
The couple were described as “deeply in love”.
In a statement to the court, Mrs Kemp’s family described her as Mr Kemp’s “rock” and as “gentle, loyal and brave”.
His family said the couple had “desperately reached out for help” but that the trust had “failed not just Thomas but his wonderful partner Katherine”.
NSFT chief nurse Diane Hull said the trust had commissioned a review alongside East Suffolk and North Essex NHS Foundation Trust (ESNEFT) to examine the treatment provided to Mr Kemp.
She said: “There is an absolute need to learn what went wrong and why, so that services can be improved and, most importantly, prevent another family suffering what Mr and Mrs Kemp’s families have been through.”
The inquest previously heard that police officers had taken the couple to A&E at around 03:00 on the day of their deaths after Mr Kemp had threatened to kill himself.
PC Andrew Overton said the couple had appeared “calm” but he had seen a large kitchen knife on the floor near Mr Kemp’s feet.
The inquest also heard Mr Kemp had been turned away by the mental health crisis team because they believed the episode was related to his anxiety about the size of his penis.
Recording a narrative conclusion Ms Devonish said Mr Kemp stabbed his wife during a psychotic episode when she tried to prevent him from harming himself.
He then cut himself, fell from a window and bled to death.
She said Mr Kemp’s “non-compliance with prescribed medication” and the “failure of the crisis response team to see [Mrs Kemp] and her husband and undertake an assessment” contributed to the deaths.
Friend of the couple Dorian Goldsmith said they were some of the “kindest people I knew”.
He said: “They were both very intellectual. They were both kind of geeky, both loved doing things like Comic Con together and dressing up.
“They both enjoyed the waterfront, you would see them walking hand-in-hand together.
“They were inseparable, they absolutely loved each other. I’ve never seen a relationship quite like it.”
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