A CORONER has criticised medical staff for systemic failings which allowed a severely depressed and suicidal woman to walk out of a secure psychiatric unit unchallenged.

Kerry Stevens, 43, of Gosling Road, Langley, left the locked ward at Wexham Park Hospital, took a taxi to a hotel where she checked in and hung herself.

The inquest at the Guildhall, Windsor, was told Miss Stevens had been admitted to Ward 10 on a voluntary basis in late October 2012, making her an 'informal’ patient.

She was severely depressed, something which she and her family believed stemmed from long-standing trouble sleeping. She admitted she had used marijuana daily for 20 years to help her relax and sleep.

After weeks on the unit she complained her medication was not working and that she was worse than she had been before her admission. As an informal patient she was able to leave the ward – to have a 15-minute cigarette break or to spend time with her family – on the approval of a multi-disciplinary team.

Under trust policy, she could only actually be released from the locked ward by a qualified staff member after a risk assessment. If it was felt she should not be allowed to leave she could be prevented under the Mental Health Act.

Mental health nurse Angela Smith told the hearing when she arrived at the ward at about 1.30pm on February 14, 2013, Miss Stevens was on her way out. Another staff member was walking away and she concluded Miss Steven’s exit had been approved.

A letter 'C’ had been put against her name on a chart, meaning she was on agreed leave, but no information was entered on where she had gone, with whom, or what time she was expected back.

When the afternoon shift began and it was noticed Miss Stevens was not around they contacted the morning shift, who assured them she was out with permission, although exactly what information was conveyed was not clear.

Several staff members were called to give evidence. They all agreed what happened was not acceptable. Family members said on an earlier occasion Miss Stevens had set off for Beachy Head, near Eastbourne, but turned back after reaching London’s Waterloo Station because her next train had been cancelled.

Her stepfather Christopher Nichols told the hearing, when he arrived at the hospital on February 14, about five hours after she had left, and realised she was not there, he had to 'pressure, pressure, pressure’ staff to raise the alarm. Through the local taxi firm they traced her to Marriott Hotel, Slough, where officers forced entry and found her dead.

Drawing the hearing, to a close, Mr Bedford accepted assurances from Berkshire Healthcare Trust that steps had been taken to address the situation.

Ward 10 no longer exists and the services have moved to Reading’s Prospect Park Hospital where there is a secure smoking area in the unit. There are also strict checks, with risk assessments made before any patient leaves.

The coroner recorded a narrative verdict after stating he was sure Miss Stevens had taken her own life.

He added: “The point is the system may not have prevented her leaving but [it] should have detected when she failed to return. That seems to be where the system failed. There were hours when nothing was done and assumptions were made.” He stressed he could not say that if the system had worked properly she would have been found in time, but there was a missed opportunity to detect her absence and begin the search for her much earlier.