Jury identifies defects in psychiatric unit's care
Elizabeth Watts' cause of death was hanging.
She died on January 28, 2011, on Bridford ward, Glenbourne unit, Plymouth.
She took her own life using shoelaces.
There were defects in care provided which contributed to the item being used. These defects were the inappropriate allocation of the room which resulted in her being distant from the staff at a time when she was so vulnerable.
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The jury decided this was "exacerbated by the missed observation at 3.45am".
The jury identified a further seven defects in procedures, which meant Miss Watts was in a position to use the item.
They stated "historically, policies and procedures had not been cascaded down sufficiently to be followed by members of the unit".
The defects were the missing observation, incomplete records, lack of clarity regarding roles, lack of a nurse in charge, allocation of tasks, the shift handover room being in an inappropriate location and the allocation of her room being unsuitable.