Mother had attempted suicide twice before

Diana Mager on her wedding day Credit: Family photo

Diana Mager suffered from chronic anxiety, delusions and began to self-harm following the birth of her daughter in November 2011.

The HSBC risk manager was admitted as a voluntary patient to Green Parks House psychiatric unit in Orpington, Kent in June of last year.

Her husband told staff that she was a suicide risk and needed to be kept on 24-hour watch.

Mrs Mager was initially placed under one-to-one observation but staff judged her symptoms to have improved and she was allowed to leave the unit for up to 30 minutes unsupervised.

Diana with baby Sofia Credit: Family photo

But on the first occasion she was allowed to leave, Diana reached the Tate Modern and tried to kill herself by jumping from a roof terrace of the building. She was stopped by a member of the public.

On another, she managed to smuggle a sharp, serrated kitchen knife into the unit.

Despite these incidents - and a note stating that "Diana is at very high risk of killing herself" in her medical records - staff were only checking on Mrs Mager at 15 minute intervals when she took her own life in the early hours of 8 August 2012.

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NHS Trust fails mother

An NHS Foundation has said it should have prevented the death of a mother suffering from post-natal depression. 33 year old Diana Mager killed herself at Green Parks House psychiatric unit in Orpington, Kent in August last year.