A 25-year-old woman who hanged herself at a Bassetlaw psychiatric hospital died after “a number of shortcomings in her care”, an inquest has found.
Cara Walls, a patient on the Emerald Ward at Rampton Secure Hospital near Retford, was found dead on the floor of her room with a ligature around her neck in February.
The inquest, hed at Nottingham Coroner’s Court, found that she did not intend to take her own life.
Now Cara’s mother, Deirdre Robinson, instructed expert civil liberties lawyers at Irwin Mitchell to investigate how her daughter came to die despite being under regular observations because of her risk of self-harm.
She said: “No other parent should get a call to hear their child has died at Rampton.
“Lessons must be learned and I want that to be Cara’s legacy.”
During the seven day inquest, the jury concluded that the ward where Cara was a patient was operating “below the prescribed staffing numbers” and that this led, on occasion, to “observations being missed”.
They also found that Cara was not observed at 15 minute intervals as required by her care plan and information about Cara’s state of mind was not passed on to incoming staff.
The jury further concluded that although it was not possible on the evidence to say that these shortcomings contributed to her death, they may have done so.
Fiona McGhie, a civil liberties lawyer at Irwin Mitchell, representing Deirdre, said: “It is a relief for Deirdre that she now has the answers she has waited so long for, even though they paint a vivid picture of Cara’s last hours at the facility, something that no parent should have to face.”
Deidre added: “Nothing can bring Cara back to me.
“But I hope that now failings have been identified, that they can be swiftly addressed so other parents can be spared the torment of losing a child in this way.”
A spokesman for Nottinghamshire Healthcare NHS Trust said: “The trust apologises unreservedly for the failings that took place in the hours before Cara’s death.
“This was not the standard we expect.
“It was made plain at Cara’s inquest that, following a comprehensive independent investigation, significant changes have since been made – especially in arrangements for observing patients.
“The trust realises that this is all too late for Cara, but we very much hope that the improvements we have made will help prevent such a tragedy in the future.
“Rampton Hospital cares for some of the most mentally unwell women in the country.
Our staff work hard day and night to keep patients safe. “Sadly, on this occasion, Cara was let down. For that, we can only apologise once again.”