A CORONER has called for a mental health trust to change its policy after hearing how a patient under its care took her own life.
Sandra Phiri, 27, of Huddersfield, was known to be a high suicide risk when she was admitted to the Beaumont Unit of St Luke's Hospital at Crosland Moor in January last year.
She had made attempts on her own life in the past and told staff that she would kill herself once she was released.
But despite these statements Miss Phiri, of New Laithe Road, Lowerhouses, was downgraded from constant observations to 15-minute observations shortly after being admitted.
A Bradford inquest was told that a few days later she used her laces and the belt on her dressing gown to hang herself in a bathroom on the ward.
Yesterday coroner Roger Whittaker said the decision to downgrade her observation level an "inevitable causal link" to Miss Phiri's death.
He returned a verdict that she took her own life while the balance of her mind was disturbed. He added that negligence was a contributing factor.
Mr Whittaker said: "I'm quite well aware that while under constant supervision there would have been little or no opportunity to take her life while on the ward.
"It seems to me that no-one within that team, when it was reduced to 15- minute observations, took on board the fact that she still had laces in her shoes and a dressing gown belt available to her."
But Mr Whittaker added that had the belt and laces been removed Miss Phiri could have still found a way to kill herself.
He said it was very difficult to provide a completely safe environment.
He told the inquest: "I hope that the hospital and the South West Yorkshire Mental Health Trust will take an opportunity of reviewing the question of taking away possible ligatures in these situations.
"It's difficult when there are other people on the ward who may have access to ligatures.
"You cannot provide a totally safe system."
The hearing was told that Miss Phiri was originally from Zimbabwe. She had suffered from mental health problems since childhood.
She suffered from hallucinations and had been admitted to St Luke's after taking an overdose.
After being placed on the 15-minute observations a nurse saw her on her way to the bathroom.
Miss Phiri said she going for a bath.
A check was made on her at the appropriate time, but she had locked the bathroom door
When it was opened Miss Phiri was found suspended from an open window.