A 30-year-old Northampton man accidentally died from illegal drugs just days after leaving a psychiatric hospital, an inquest heard.
Stephen James Martin was found dead in his new care flat in St George's Street, off Barrack Road, in August 2016, just three days after being discharged from St Andrews Hospital.
He had moved into the flat for community treatment under Maplyn Care Services, and the inquest heard he "seemed positive" about moving out of the Northampton hospital.
But three days later, on August 4, a carer found Stephen dead after overdosing on the opioid phenylfentanyl.
At his inquest yesterday (November 1), the coroner heard how Maplyn was commissioned to have face-to-face meetups with Stephen for three hours a day - but he was only seen for an hour in total in the three days leading up to his death.
Managing director of Maplyn Peter Evans, who gave evidence, said: "We cannot be sure when or how he got his hands on the phenylfentanyl.
"Since dealing with this incident we're highlighted areas in our service we need to ensure are more robust."
Mr Evans said that the three hours of contact a day were "fluid" and were not always rigid.
The inquest also heard how Stephen had been considered for a transfer from St Andrew's to the Maplyn flat earlier in 2016 - but this was pushed back after he bought alcohol and drugs before going missing.
This raised questions about whether Stephen had been released from the hospital too soon.
St Andrews, Maplyn and the NGH NHS Foundation Trust were also criticised for a lack of communication with each other.
Senior coroner Anne Pember said: "Stephen was discharged into a community treatment order. He should have been seen by the support staff and there was a failure to do this."