Mia Titheridge inquest: Teenager died after checks missed by nurse
A suicidal teenager under 15-minute observations took her own life when a nurse failed to check on her for almost an hour, an inquest found.
Mia Titheridge, 17, who had told staff she was not being checked properly, was found in her room at Huntercombe Hospital, Norfolk, in 2017.
CCTV showed nurse Olaoye Fagbemiro did not check her for 57 minutes.
Norwich coroner Jacqueline Lake said she was considering a prevention of future deaths report over the case.
The inquest jury returned a conclusion of suicide and found there was a failure to respond to Miss Titheridge's low moods and suicidal thoughts, and a failure to carry out frequent observations overnight on 18 and 19 March.
The teenager, from Yorkshire, had a history of self-harm and was transferred to the secure hospital at Buxton near Norwich in December 2016 after she threw herself in front of a car.
She was diagnosed with emotionally unstable personality disorder and was receiving psychological treatment.
The nine-day hearing was told she visited her mother a week before her death and on her return was subdued and did not eat.
No further action
It was agreed by staff that she had deteriorated but her observations were kept at 15-minute intervals rather than continuous, the jury heard.
On the night of 18 March she told a support worker she was not being checked properly.
At 01:56 on 19 March she was discovered in her bed and died later that day of compression to the neck and a brain injury.
CCTV footage viewed by police proved she was checked four times instead of eight between 23:30 and 01:30 and not at all between 00:59 and 01:56.
Norfolk Police took no further action against Mr Fagbemiro or the hospital, the inquest heard.
Ms Lake said she would write to the Nursing and Midwifery Council about Mr Fagbemiro's fitness to practise and the Royal College of Psychiatrists and the General Medical Council about "professional curiosity".
Huntercombe Group, which has 22 specialist hospitals in the UK, ran the hospital before it closed in December 2017.
It said it supported the coroner's actions and would conduct spot checks to ensure staff duties were met.