A man who died during a police chase after absconding from hospital was let down by failings in mental health services, a damning report has revealed.

Ben Rich, 37, had been sectioned under the mental health act at Kingston hospital two days before his death in February 2017.

Last week the family’s lawyer told of their two-year wait to find out what happened, adding that the family felt let down after entrusting Mr Rich to a mental health hospital.

A safeguarding adult review, obtained under a Freedom of Information Request, revealed Mr Rich was not properly assessed after being moved from Kingston to Springfield hospital in Tooting.

He endured excessive waiting times, which caused him to become “agitated”, and decisions were made by inexperienced staff despite his history of mental illness.

Almost 24 hours after being sectioned he ran out of hospital, to his home in Richmond where he got into his Audi TT. Police pursued Mr Rich for nearly seven miles. He crashed near Kempton and died.

In a statement, the family lawyer said: “Sadly Ben was not given the proper care expected of staff at Springfield hospital and his death uncovered a series of systemic failings by the trust.”

She added: “They had to endure two years of not knowing the truth of what happened to Ben, which is simply unacceptable.”

Mr Rich’s family described him as “intelligent, gentle, witty and popular”. After university, he worked in banking and as a management accountant.

His family called an ambulance on February 6, 2017, because of a deterioration in his mental health.

The former Richmond man was taken to Kingston hospital, where Mr Rich initially agreed to be taken to Springfield. He was eventually sectioned by police when he tried to leave and taken to the Tooting hospital just after midnight — almost nine hours later.

He waited in the ambulance outside the hospital for over three hours to be admitted, according to the report.

A referral to the hospital day team was not received due to an “IT error” and further assessments were never completed. Mr Rich, still under section and not legally allowed to leave the hospital, was then “stepped down” — a process which meant he was transferred to an unlocked unit for voluntary patients.

The form was signed by an “unqualified associate nurse” and verbally approved by the matron, who was not directly involved in Mr Rich’s care, according to the report. The decision should have been taken by a consultant psychiatrist, ward manager or deputy ward manager.

An internal inquiry by the South West London and St George’s Mental Health Trust, which runs Springfield, “acknowledged the necessity for the improvement of systems”. The safeguarding adults review made four recommendations, including that it “review the impact of policy changes to ensure the safety of patients”.

A spokesman said: “This is a very sad incident and we continue to extend our deepest sympathies to the friends and family of Mr Rich.”

He said they had met all the recommendations in the report, including ensuring appropriate security measures are in place.