The family of a depressed man who killed himself claim he was let down by the system.

Shaun Nutman’s widow Amanda spoke out after a coroner called for a review of her husband’s counselling in the lead up to his death and said “Shaun was let down under their care”.

West Dorset Coroner Michael Johnston is writing to Dorset Primary Care Trust after hearing how Mr Nutman had just one hour of counselling a week and was not seen by a psychiatrist.

An inquest in Dorchester was told how Mr Nutman, 33, of Chickerell Road, Weymouth, battled depression, anxiety and Obsessive Compulsive Disorder and he and his GP called for more counselling.

Mrs Nutman said she was assured by her husband’s GP Dr Orrell and his counsellor Katherine Price that he would not kill himself.

But on the evening of November 1 last year he took his children to bed and read them a bedtime story before later that night going into the garden and stabbing himself in the chest.

Mrs Nutman, 31, said thoughts went through his head “like a machine gun” and became worse on the night he died.”

Shaun would not let her phone his dad Roy for help and told her if she knew what he was thinking she would call the police, the inquest heard.

She said: “I said ‘Shaun you’re scaring me.’ “He said ‘My mind has gone and I’m not even anxious - feel my pulse’.”

Mrs Nutman ran outside and used a passer-by’s phone to ring her father-in-law but when she returned her husband had taken a knife into the garden. His father arrived and a neighbour tried to use CPR but it was too late.

Mr Johnston asked Dr Jonathan Godfrey, the consultant psychiatrist in charge of Mr Nutman’s case: “How better could this have been handled in light of what’s happened?”

Dr Godfrey replied: “With the information we had at the time I think it was handled quite appropriately.”

But Mr Johnston later asked: “What do you have to do to get somebody to see you?”

The inquest heard that Dr Godfrey had decided to refer Mr Nutman from the Improving Access to Psychotherapy team to the Community Mental Health Team on November 2 – but by then Mr Nutman was dead.

Katherine Price, High Intensity Cognitive Behavioural Therapist, said she knew Mr Nutman had suicidal thoughts on “most days” but always said he did not want to do it.

Mr Johnston said he needed evidence that Shaun Nutman intended to kill himself to record a verdict of suicide and said he was giving a narrative verdict instead as he believes he was in “such distress from his obsessive compulsive behaviour that he probably really hardly knew what he was doing.” Mr Johnston said he had the right to suggest there had been “room for improvement” in Mr Nutman’s counselling.

He added: “I think there’s room for the trust to look at what happened and learn from it because I don’t want to be listening to similar cases and they are required by law to respond to my letter.”

Speaking afterwards Mrs Nutman said she was “really pleased” with Mr Johnston’s proposed letter to the PCT.