Peter Brown, 46, from Whitby, was being treated for a depressive disorder at Cross Lane mental health hospital in Scarborough, where he had been admitted on May 1 in 2019.

He had not been detained under the Mental Health Act and was allowed to leave the ward, and on May 8 was granted permission to do so by a nurse on condition that he returned by 7pm.

Mr Brown, who ran his own painting and decorating business, did not come back by 8pm, and was reported missing to North Yorkshire Police. Over the course of the evening, his risk level was increased from medium to high, large numbers of officers were deployed to search for him and a dog unit and Coastguard helicopter were sent to the scene.

The force's search adviser was ‘satisfied’ that all steps had been taken to locate Mr Brown, and told the inquest at North Yorkshire Coroner’s Court that it was ‘not easy to find someone in the large search area indicated’.

British Transport Police officers were sent to search the area around the railway line leading to Scarborough Station. On May 10, they spent four hours checking each side of the tracks, but told the hearing that some areas of ‘thick undergrowth’ could not be searched. They were told to only attempt to do so if they could seen signs someone had tried to enter the snicket.

It was in one of these patches of undergrowth, which had subsequently been cleared, that two railway workers found Mr Brown’s body hanging from a tree on January 21 in 2021 – 20 months later.

Some of Mr Brown’s medical history was given to the hearing by his wife Natalie, with whom he had two children, and who said he had had difficulties with his mental health since 2008. For around a decade his condition was managed by his GP, but he deteriorated in 2018 and he was referred to specialist psychiatric care. While he was being treated at Cross Lane, both she and the doctors felt he should remain in hospital at the final review meeting before he went missing.

Clinicians on the ward did not believe he had suicidal thoughts or any intent to harm himself, and were surprised when they learned that he had died. His leave request had been granted because he had always returned promptly when he had been allowed out on previous occasions.

Senior coroner Jon Heath considered evidence from a woman who believed she had seen and spoken to Mr Brown walking through Burniston on May 12, but decided that it was unlikely to have been him as the descriptions of his clothing did not match.

Recording a conclusion of suicide, Mr Heath said: “The postmortem could not say how long he had been dead before he was found, even approximately. I do not think Pete would have been found if he had been graded as high risk earlier.

"It is not possible to say when he died, but I suspect it was within hours of him leaving hospital on the 8th.”

Peter Brown inquest: Yorkshire dad, 46, found dead nearly two years after he went missing in 'thick undergrowth' that police decided not to search