A coroner has criticised the care of a mentally ill patient who died after stealing and crashing an ambulance.
Michael South, 40, from York, was being transported to a mental health hospital when he took the vehicle in April.
He crashed into a double-decker bus on the A64 at Flaxton, near York and died at the scene.
Recording an open verdict, North Yorkshire Coroner Michael Oakley said the transport arrangements had been "inadequate and insufficient".
He said the Leeds and York Partnership NHS Foundation Trust had failed to pass on Mr South's full medical history to the ambulance provider.
He also said the two staff onboard had not had mental health training and the company, ERS Medical, had not done a full risk assessment of the patient.
Keys in ignition
Mr South had been admitted to St James's Hospital in Leeds after stabbing himself in the chest on 7 April.
He was being taken to Bootham Park Hospital in York in an ambulance operated by the private contractor ERS Medical on 10 April.
The two ambulance staff told the inquest they had left the vehicle after Mr South attempted to grab the wheel.
The keys had been left in the ignition and he was able to drive-off.
Following the inquest, Mr South's widow issued a statement through her solicitor.
"He needed professional help and for the reasons the coroner has given he didn't get adequate help. It led to Michael's death," she said.
She added she hoped system changes would in future protect vulnerable people, like her husband, and the wider public.
ERS Medical, The Leeds and York Partnership NHS Foundation Trust, which operated Bootham Park hospital at the time, and the Leeds Teaching Hospitals NHS Trust, which runs St James's, said there were "lessons to be learned" from Mr South's death.
The three organisations also expressed their condolences to Mr South's family.
All said significant changes had already been made and NHS England was carrying out a full investigation into his death.