The family of a grandmother who died in a motorway bridge fall after failings by her carers have said health chiefs could have prevented her death.
Distressed Marion Munns, 74, escaped from her Southampton home through an upstairs window before climbing off the garage roof and running away.
Her body was found on the M27 motorway and the inquest was told that she died of severe multiple injuries.
Speaking after the inquest, Mrs Munns' family said they were considering legal action against Southern Health.
Daughter Angela Mote, 55, said: "The woman my family saw that night simply wasn't my mum. My mum was a gentle, giving woman who would do anything for anyone. That night she was a woman in the depths of crisis and help simply didn't come."
The case has been a "wake-up" call for the under-fire Southern Health NHSFoundation Trust, said Coroner Grahame Short.
He concluded that a number of failings had been made by the Trust but added that he was satisfied it had amended its practices.
The inquest in Winchester heard that the mother-of-two had previously been admitted to hospital in Southampton for three months in 2014 for depression but returned home after showing improvement.
However, her condition deteriorated again the following year and the grandmother died on 12 November, 2015.
Mr Short ruled that no specific action had led to Mrs Munns' death because she was suffering a manic episode after failing to take her anti-psychotic medicine, risperidone.
He said the failings identified in her care included no risk assessment, care plan or contingency arrangements in case her condition deteriorated in the way it did.
Recording a narrative verdict, Mr Short said: "I believed it served as a wake-up call and I am satisfied the steps have been taken to address these shortcomings.
"I believe the older persons mental health team is probably under-resourced to deal with an increasing number of cases such as Marion Munns as the population ages."
Julie Dawes, interim chief executive of Southern Health, said in a statement: "In the past, the Trust has not done enough to involve families during the care of or following the death of a loved one. We still have a lot to do in this area, and I am absolutely committed to driving through the necessary changes within the organisation.
"The internal investigation we have conducted into Mrs Munns' death highlighted a number of concerns, and we are pleased that our efforts to address these have been recognised by the coroner."