A series of inquests heard that three patients from the same mental health ward all died in front of trains in a matter of weeks.
The hearings were held into the deaths of mother-of-two Gillian Watkinson, 49, former chef Matthew Brookes, 26, and Leyland man Paul Knowles, 35, all patients of Healey and
Yarrow wards at Chorley and South Ribble Hospital.
Sewing machinist Gillian, of Yewlands Drive, Leyland, married for 20 years to John, died at Leyland station after being allowed out of the female ward, Yarrow, on "escorted home leave" with her husband as escort.
She was admitted on November 29, 2004 after an incident at home in which daughter Amanda had to fight to get a noose away from her.
In 2004, she became anxious and obsessive and began going to Leyland Station, admitting she was thinking of suicide. On Yarrow ward, she told staff she wasn't suicidal, but other patients told them she planned to jump under a bus.
She leapt from Leyland station platform.
Coroner Carolyn Singleton said it was not certain she intended suicide and recorded a narrative verdict.
Ward staff explained to Mr Watkinson that "escorted leave" meant she must be watched constantly but seemed unsure who exactly told him, admitting there were no written instructions.
John Watkinson said it was not made clear and told the inquest: "I certainly didn't have enough guidance.
"I'd no experience at all before. I feel we were let down."
Daughter Katie said afterwards: "I would have said, 'Handcuff her to the bed'.
"I wanted her in hospital where I knew she was safe. I never knew what I was coming home to.
"You'd think, 'Is she going to be hanging in the garage?' "
In another case, alcohol dependent Paul Knowles, of Meadowcroft Road, Leyland, was admitted for detox on December 11, 2004, and discharged on January 4 despite admitting thoughts of self-harm.
His first follow-up was an appointment on January 13 – as the only alcohol counsellor in the area was on holiday.
He was readmitted next day after slashing himself with a hypodermic.
Discharged again on January 6, he reappeared four times on the night of January 7 to 8, smelling of drink and pleading to be readmitted. Staff told him to go to A&E to be assessed.
Next morning, police found Mr Knowles dead of multiple injuries on the Chorley line. No note was found and a narrative verdict was recorded.
Matthew Brookes, of Fowler Lane, Leyland, who suffered anxiety and depression, walked off Healey ward at 9.10am on January 11 2005 and leapt to his death 20 minutes later, the court heard.
The inquest heard that, on the morning of his death, five staff were stretched.
Matthew and two others also disappeared.
At Matthew's inquest Joe Crocock, adult services manager for Lancashire Care Trust, said staff now noted when patients left.
He also said a 24-hour crisis team was in place to help patients after discharge – but not for cases of substance abuse like Mr Knowles.
He described plans to replace the current 15 units with three wards, but this "would take five or six years".
Coroner Dr James Adeley said: "Matthew took his own life because the risks of him doing so were not recognised."