An investigation found ‘missed opportunities' and ‘shortcomings' at the services contributed to the death of 40-year-old Ebow Graham following a psychotic episode.

The investigation found paramedics had wrongly left without seeking the opinion of mental health specialists and assuming Graham had capacity to decline treatment after being called to his flat in Clapton, East London.

A call handler at the mental health crisis line was then found to have ‘underestimated' Graham's condition and ‘potential risk' after arranging for him to be called the following morning after being contacted by his friends.

Graham's friends then took him to hospital but he left before being assessed due to a long wait. Having returned home he fell from a third-floor window and subsequently died after arriving at hospital.

Leena Savjani, the expert medical negligence lawyer at Irwin Mitchell representing Graham's family, said: ‘While nothing can make up for Ebow's death we're pleased that we've been able to provide them with the answers they deserve.

‘However, it's now vital that lessons are learned from the issues that have been identified to help improve patient safety in relation to mental health.'

London Ambulance Service and East London NHS Foundation Trust, which ran the crisis line, paid an undisclosed settlement to Graham's family after admitting they had breached their duty of care.

Daniel Elkeles, chief executive at London Ambulance Service, said: ‘We would like to offer our sincere condolences to Mr Graham's loved ones and we are sorry for the shortcomings in the care we provided to him in the hours before his death.

‘The inquest found we should have sought mental health specialist advice on whether Mr Graham had capacity to decline treatment. However there was no finding of racial profiling and these are claims we strongly refute.

‘We carried out an investigation into the care of Mr Graham and there has been much learning and action for the trust in the five years since he died.'