Royal Blackburn Hospital left suicide risk patient Jackie Williams unattended

Jackie Williams
Image caption Jackie Williams should not have been left in a cubicle with a closed door, the coroner said

A suicidal woman was able to hang herself when left unattended at a hospital because of failings and misunderstandings, a coroner has said.

Recording a suicide verdict Michael Singleton said Jackie Williams, 42, was not "appropriately managed" at Royal Blackburn Hospital.

Mrs Williams was hanged in a cubicle at the A&E ward on 27 January.

The East Lancashire Hospitals NHS Trust and Lancashire Care NHS Foundation Trust said patient safety has improved.

Mrs Williams was admitted to hospital late on 26 January after being found unconscious and intoxicated by a canalside in Burnley.

'Clear misunderstanding'

The inquest heard hospital staff were aware she was suicidal but Mr Singleton said it was not made "adequately clear" the cubicle door should remain open.

The Blackburn Coroner said not only did Mrs Williams have suicidal thoughts but she was put in an environment in which she could act on those thoughts - a room with potential ligatures and ligature points.

He also said there was "no effective referral" of the patient to the mental health liaison team at the hospital and there was "clear misunderstanding" between nursing and mental health staff that meant Mrs Williams was left unattended and not seen by an appropriate specialist.

Mr Singleton is preparing a Regulation 28 report - which allows coroners to highlight concerns to prevent future deaths - but said he had already been impressed by the manner in which both the hospital trust and the Lancashire Care NHS Trust had already addressed some issues.

Both hospital trusts said patient areas had been reviewed to reduce the risk of self-harm with better observation of high risk patients.

Mrs Williams's husband Wayne was asked if he was satisfied with the inquest outcome but said he was not.

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