A CORONER has called for major changes at a hospital after a patient was able to hang herself in a public toilet outside a mental health unit.

The coroner is now drawing up a report calling for a raft of improvements at Kendal’s Westmorland General Hospital (WGH) following the death of Katie Inman, 44, from Storth.

She was found in a toilet next to the hospital’s in-patient mental health unit last May, hanging from her dressing gown cord.

An inquest was told that a month before she had made at least two attempts to end her life and had told staff she was having suicidal thoughts. But nurses from Kentmere ward at WGH did not think these comments or attempts were 'serious', the hearing in Kendal was told.

Ian Smith, the south and east Cumbria coroner, criticised the trust for not providing him or Miss Inman’s family with a full report of an investigation into the ward following her death.

And he said he would now issue a report calling for improvements to be made on the ward to prevent a similar tragedy happening in the future.

He wants to see:

* improved security and supervision for mental health patients in Kendal.

* better staff training in risk assessment

* more effective co-ordination between staff

* more liaison with families

Cumbria Partnership NHS Foundation Trust said it had already begun to take action, including making changes to procedures, training and patient assessments.

Trust area manager Meryl Taylor admitted the level of service was ‘not adequate’ and said that 'lessons had been learned'.

She said there had now been changes to staff training, handovers at the beginning of shifts and the manner ward reviews were carried out.

The two-day inquest heard that a week before her death Miss Inman had made a noose out of a dog lead during a home visit with her mother Rachel.

The hearing was told it was general practice to leave the ward unlocked during the day, which let Miss Inman leave without anyone noticing.

She was reported missing at around 1pm and found hanged in a public toilet close to the ward, which had not been checked for around 45 minutes.

Kentmere unit consultant Kenneth Wood said in hindsight she should have been put on continual observation.

Ms Inman's sisters, Helen Stevenson and Julie Hodgkins, both said they tried to warn staff about her mental state.

Mrs Hodgkins said: "The day before, I saw some marks on Katie's neck when I was talking to her.

I said: 'What have you done?' She didn't want to talk about it. I had a chat with a staff member and she said she didn't regard it as a serious attempt."

Mrs Stevenson said she phoned staff on the night of May 5 warning them Ms Inman was of 'high risk of suicide' and worried about her having unescorted leave and a dressing gown cord in her possession.

Assistant nurse Jamie Shepherd said he went through her belongings on May 5 to remove anything of danger after she had told him she was having suicidal thoughts. But he did not find the cord she ended up using.

Mr Smith said a series of signs had not been taken seriously between March 22 and May 6.

On May 6 it was written in Ms Inman's notes at 5:40am that she had tried to leave the ward, when stopped she said: 'I need to go, I can't handle this any more'.

Dean Stilling, the nurse in charge on May 6, said that when he started his shift he was not made aware of her notes.

Recording a narrative verdict, Mr Smith said: "Katie Inman died as a consequence of her own actions at a time when she was suffering from an acute episode of a long term mental illness which was being assessed by the Kentmere ward at Westmorland General Hospital."

Westmorland and Lonsdale MP Tim Farron said: “It is a massive tragedy.

"The best that can be hoped for is proper lessons are learned.

"The ward has had major investment and is probably the most improved in the north west."

An NHS Cumbria spokesperson said it had been assured by the Cumbria Partnership NHS Foundation Trust that it would act on the recommendations.