Kieran Hubbard, 20, who had recently broken up with his girlfriend, was referred to a senior psychiatrist after he was found at the top of a motorway bridge.
But although the consultant recommended Kieran be admitted as an inpatient due to concerns for his safety, healthcare professionals overruled her and instead suggested he be seen at home.
The following day Kieran drove to a building site where he had been working in Ancoats, Manchester and hanged himself inside a former mill he was helping renovate.
In the minutes before his death he left a series of notes reading ''love and goodbye'' and sent a heartbreaking Facebook message to his father Kevin saying his mental condition had left him “paralysed with an overwhelming sense of fear.”
In his message, Kieran said: “It sounds ridiculous to anyone who doesn’t suffer with mental health but I wouldn’t wish it on anyone.
"It completely takes over you mentally and physically. It’s like a complete state of trauma and you can’t speak, feel an urge to cry, too scared to be with anyone but not wanting to be alone, feeling lost about what to do or how to do it.
“Feeling in a daze and simultaneously being unaware but also aware of everything around you.
"You just want to stay in bed and escape but then you fear what other people are thinking if you don’t act normal, this continues until either you just give up through exhaustion or collapse and fall asleep.”
Mr Hubbard, 44, a director of the construction company Kieran was working for raced to the scene after getting the message but by the time he arrived his son was already dead.
He was later found on a motorway bridge and referred to the Greater Manchester Mental Health Team for a psychiatric assessment.
Mr Hubbard told the Manchester hearing: ''He knew we loved him but he couldn’t get the suicidal thoughts out of his head. It was becoming more and more frequent but he said but he said he had no intention of doing it.
“The very last time I spoke to him properly was at 10am on February 8. He was very calm and said he was fine.
"I offered to go pick him up and bring him to Norfolk because I didn’t want him on his own. He was adamant he was fine and wasn’t at risk, in a good place.
“He was going to go see the baby that afternoon he seemed quite happy he seemed fine, he had new medication, so he was going to start that.
“But then one of his friends phoned me up and said you better get in touch with Kieran he has posted something.
“Straight away as soon as he said it I panicked. I immediately packed up work and tried ringing him no end of times and he wouldn’t answer.
“When I got in the car and set off, he did answer and he just said ‘I love you’.
“I phoned the Salford Mental Health unit and told them to get to him but they advised me to phone 999.
''I had numerous calls from the police on the way asking me his car registration and I was trying to tell them the site address.
"I got there and went straight round the back and saw Kieran’s car.''
Dr Suraya Khan, consultant psychiatrist said Kieran was referred to her on February 4 and added: ''I was concerned about him being in acute mental health crisis and I concluded he was suffering from a recurrent depressive disorder.
"At that point he was suffering a current severe depressive episode and it was marked by recurrent suicidal thoughts.
“His depression had all the core features – loss of interest and enjoyment, pervasive low mood and lack of energy.
"He also had poor sleep and poor concentration, feelings of helplessness and worthlessness.
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