A coroner has criticised an NHS trust for failing a woman who fell to her death from a motorway bridge.
Marion Munns, 74, died on the M27 near Southampton in November, after suffering a mental health breakdown.
Her death was a "wake-up call" for Southern Health although no single action had caused it, coroner Grahame Short told the inquest in Winchester.
The trust has apologised to Mrs Munns' relatives, and accepted the coroner's findings.
The hearing was told Mrs Munns behaved erratically in the weeks before her death, obsessively drinking water and shouting out numbers.
On 12 November, she became agitated and aggressive at her Southampton home.
Her daughter, Kim Vella, 57, said she phoned her mother's Southern Health carer but was told the office was closing and she should dial 999.
In her evidence earlier, the carer Emma Bulbrooke said she tried to phone several doctors and two mental health units, but no one was immediately available.
The inquest heard there was no dedicated out-of-hours service for older mental health patients because the NHS would not fund one.
While the family waited for help, Mrs Munns fled through an upstairs window.
Her body was later found on the motorway at Rownhams, two miles away.
In a narrative verdict, Mr Short said Mrs Munns' failure to take her anti-psychotic medication led to her death.
But, he said Southern Health had also failed to put in place care plans or a risk assessment.
Her daughter Angela Mote said: "Their policies, their procedures, are only in writing... We tried to get our mother seen [by a consultant] and yet we failed."
The family said it was considering legal action against the trust.
In a statement, Southern Health said it had made "comprehensive changes" to its Older Persons Mental Health Service.
Interim trust chief executive Julie Dawes said: "We fully accept the coroner's conclusion and acknowledge that some of the care arrangements for Mrs Munns could have been better."