A mentally-ill man died from self-inflicted stab wounds after being released from hospital.
Michael William Hall used a knife to harm himself and took a large number of tablets, an inquest heard.
The 44-year-old grandfather had been discharged from Cherry Knowle Hospital, in Ryhope, the day before after spending a week there.
A mental health worker visited his home in Fatfield, Washington, on the day he died in May, but eventually left after getting no response to knocks and phone calls.
Mr Hall's daughter discovered his body later that day, when she visited the house with her five-year-old son.
Pathologist Dr Jennifer Hamilton explained that he died after inflicting 54 injuries on himself, striking vital organs.
She told the inquest at Sunderland Civic Centre that there was nothing to suggest anyone else was involved.
Paracetamol, other medication and receipts from local pharmacies were found in the house, along with a knife and a razor.
Support worker Laurie Crow, from the Mental Health Crisis Team, tried to visit Mr Hall on the day he died.
He told the inquest he had never met Mr Hall, but was advised he could be "evasive".
"On reflection I would not have done anything different on that particular day."
He added: "Because of the notes I had been given by the nurse I did not feel any great concern.
"I certainly would not have left the home if I had had any great concerns."
Coroner Derek Winter heard Mr Hall's daughter and son both had keys to the house, but were not contacted.
Helen Pike, lead practitioner with the Crisis Team, said new protocol had been introduced since Mr Hall's death.
His daughter, Leanne Smith, fromBarmston, Washington, said: "You could tell he was feeling down in his face. He was like a lost little boy.
"He was not the easiest man to talk to or get on with. I could see the Sunday I went to see him that he was not himself.
"He should not have been released, no way, not after a week."
Coroner Derek Winter recorded a verdict of intentional self harm.
He also asked Crisis Team bosses to write to him within six weeks about changes to procedure.
"When there is a negative visit, there should be some protocol in place.
"Mr Crow should have had available at his fingertips the numbers of family members."
"It may give this family some comfort that something good can come out of this tragic sequence of events," he added.
Verdict: Intentional self harm.