A man's life could have been saved by Mental Health Services, but they failed to intervene before he killed himself.
That from Coroner of Inquests John Needham, who recorded a narrative verdict at the inquest into the death of 35-year-old Onchan man Christopher Burrows.
Mr Burrows was found hanged at his home in June 2011, two days after leaving Grianagh Court day treatment facility.
Mr Needham said Article Two of the European Convention on Human Rights - which protects people's right to life - had been breached.
He said Mr Burrows killed himself, but the state missed an opportunity to prevent that the day he died.
Mr Needham said at a clinical meeting hours before Mr Burrows's death, no-one suggested a risk plan, which which would have immediately protected him.
He listed eight recommendations for Health Minister David Anderson, to improve the Island's Mental Health Services.