'We don't blame dad for killing mum, he was ill'

Chris and Ruth were loving and caring parents, Oliver and Abbie Stone-Houghton said, and devoted to one another.

"We had such a brilliant childhood, and even in their adult life we were so close with both of them," explained Abbie.

Chris ran a jewellery business which Ruth had also worked in. He had no previous mental health issues but as the company struggled during the Covid pandemic, eventually closing in April 2022, he began to experience delusional thoughts.

He became increasingly paranoid, wrongly believing he was being listened to by his phone and computer, and terrified someone was out to get him. He became withdrawn, looked noticeably frailer and experienced suicidal thoughts.

"He didn't feel like he had anything to offer anymore," his son Oliver, now 30, remembered.

Chris was eventually diagnosed with psychotic depression, and in July 2022 attempted to take his own life.

He was sectioned and placed on a mental health ward at St James' Hospital in Portsmouth, run by the local NHS trust, where the family believed he would spend several months.

Within four weeks, he was discharged back home against the family's wishes. Ruth was "terrified" that her husband would further self-harm, the inquest heard.

Being a loving family worked against them, Oliver said, believing staff felt "they didn't have to worry so much about him being returned home than perhaps in other cases".

"We didn't really get any advice on what to do, what not to do," said Abbie. "We were just doing what we thought was right and just hoping for the best really."

Consultant psychiatrist Dr Denzel Mitchell, who worked at St James' Hospital, said the decision to discharge was made in large part because Mr Stone-Houghton had not self-harmed or had psychotic episodes on the ward.

Coroner Rachel Spearing found that though the decision was "appropriate", the way it was carried out was "unsafe", with an "inadequate risk assessment".

Chris had a history of refusing anti-psychotic medication at home, and had to be cajoled into taking it in hospital, but this was not adequately considered. The family had not been fully supported given the burden placed on them to ensure he took his medication, Ms Spearing added.

She found it was "unlikely" he had taken his medication at the time of the deaths.

There had also been a lack of access to support, the inquest heard. Chris had not received psychological intervention in hospital, because the ward did not have a psychologist.

Once back home, his community crisis team twice asked for Chris to have early intervention for psychosis treatment, the best and quickest option available, but this was denied.

Chris was 66, and the NHS trust's cut-off age for the service was 65.

"Had he had that treatment, we don't know what would have happened," said Oliver.

Chris was instead placed on a year-long waiting list for specialised talking therapy support.

The plan was for the family to alert the crisis team if they noted signs of relapse, the inquest heard, but no formal carer's assessment had been carried out for Ruth, 60, who looked after her husband.