Oxfordshire's coroner is to write to mental health authorities to ask how a retired Army captain from Bicester who threw himself in front of a train was dealt with by medical staff before his death.
An inquest on Wednesday heard how former soldier Derek Modral died on August 30 when he dashed in front of the 95mph commuter service at Bicester North railway station, 10 minutes from his home in Willow Drive.
His family, who attended the hearing at Oxford Coroner's Court, suggested that he was not properly cared for by medical authorities.
The 68-year-old grandfather, who was married to Eileen and had two sons and two daughters, was killed instantly.
Mr Modral was described by his family as "the last person you would expect to take his own life" but had a rapid decline between the end of 2015 and his death.
They said that their views had not been properly taken into account by those responsible for his care.
He had not been seen by a clinician for 12 days when he took his own life.
Despite his poor mental state, no assessment was made when Mrs Francis went on holiday, which his family believed could have saved him.
A root cause assessment (RCA) carried out by the Oxford Health NHS Foundation Trust identified that "relapse symptoms" were missed after he was released from hospital, and that a period of time passed between August 18 and September 1, with no contact by clinicians despite a deterioration in Mr Modral's condition.
Oxfordshire coroner Darren Salter issued a Section 28 coroner's report to the Trust, regarding family liaison input and missed opportunities, and risk assessment when staff were on leave.
This requires the Trust to respond within 56 days to say what action it plans to take.
A conclusion of suicide was recorded.
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