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Criticism follows ambulance tragedy.

The North Yorkshire coroner has criticised the care of a mentally ill patient who died after stealing and crashing an ambulance.

The patient, Michael South, 40, from York, was being transported to a mental health hospital when he took the vehicle, which has the keys in the ignition, in April 2015.

He crashed the ambulance into a double-decker bus on the A64 at Flaxton, near York, a dual carriageway and died at the scene.

North Yorkshire Coroner Michael Oakley, recorded an open verdict and said the transport arrangements by Leeds and York Partnership NHS Foundation Trust had been "inadequate and insufficient.”

Details of Mr South’s full medical history had not been passed on by Leeds and York Partnership NHS Foundation Trust to the ambulance provider. Mr Oakley also that the two ambulance staff  had not had mental health training and the company, ERS Medical, a private contractor, had not done a full risk assessment of the patient.

Mr South had been admitted to St James's Hospital in Leeds after stabbing himself in the chest on 7 April. He was being taken to Bootham Park Hospital in York in an ambulance operated by ERS Medical on 10 April.

The two ambulance staff told the inquest they had left the vehicle after Mr South attempted to grab the wheel. As the keys had been left in the ignition, he was able to drive-off.

Following the inquest, Mr South's widow issued a statement through her solicitor. She said: "Michael needed professional help and, for the reasons the coroner has given, he didn't get adequate help. It led to Michael's death.”

She added she hoped system changes would in future protect vulnerable people, like her husband, and the wider public.

ERS Medical, The Leeds and York Partnership NHS Foundation Trust, which operated Bootham Park hospital at the time, and the Leeds Teaching Hospitals NHS Trust, which runs St James's, said there were "lessons to be learned" from Mr South's death.

The three organisations also expressed their condolences to Mr South's family.

All said significant changes had already been made and NHS England was carrying out a full investigation into Michael South’s death.