THE mother of Daniel Heard has criticised the health organisation that allowed her son to walk to his death.

Daniel, 26, who suffered from schizophrenia and paranoia, had been detained at The Cedars, Exeter, run by Devon Partnership Trust, under the mental health act.

But, despite close observation, he walked out and died in freezing conditions.

He had been under 15-minute observations and had expressed many times that he wanted to leave the premises.

On February 24, 2004, he succeeded and five days later his dead body was found in a field in Hele, near Bradninch.

As an inquest concluded yesterday, Exeter and district coroner Elizabeth Earland made a series of recommendations in a bid to ensure the events were not repeated.

And Daniel's mother, Lynda Kelly, said that her son's death had been "tragic, unnecessary and wholly avoidable".

The words were read out by Mrs Kelly's legal representative Richard Stevinson.

He also said that despite the inquest lasting nearly five weeks, it had not been possible to establish some facts leading to Daniel's death. That, he said, was due to a range of reasons, including documentation not being disclosed by the trust, nurses involved at the time not giving evidence, and the delay in opening the inquest.

He said: "This inquest took place nearly five years after Daniel's death.

"It is often the case, as it is here, that 'justice delayed is justice denied'."

He added: "Mrs Kelly is not convinced that the trust has taken any significant steps in the intervening period of nearly five years to improve the system of monitoring the doors to the unit.

"Patients who are detained under the Mental Health Act and who are not supposed to leave the unit are still at will to go.

"There is no reason why a similar incident to that which involved Daniel could not occur again now. Indeed there are reports of a patient having left from The Cedars this week, and having remained out over two nights before being found safe."

He added: "On so many different levels, Daniel's death was avoidable.

"Daniel's mother sincerely hopes that the death of her son will allow lessons to be learned to prevent similar tragedies."

Mrs Kelly later spoke to reporters and said she wanted Daniel to be remembered as someone who "loved to make people laugh, a peace-loving person, loved being an uncle, gentle."

She added she felt relief that the inquest had come to a close, as she felt she was finally being taken seriously.

Her relief came after the jury returned a narrative verdict — stating that Daniel died in the late evening of February 24 2004, the same day he absconded from The Cedars unit.

The coroner told the court: "We've all been touched by this tragedy and I, and my officers and anyone involved in this case very much hope that Daniel's death has prompted lasting change that will help those that come after."

She offered her condolences to his family "who have had to wait so long for this day and had to endure so much".