Video report by Katie Cole
A North East mental health trust has apologised to the family of a young musician who was found dead on one of its hospital wards.
A jury has ruled that there was a failure in the care given to Mina Topley-Bird, from London, who took her own life at West Park Hospital in Darlington in May 2019.
Following her death, Tees, Esk and Wear Valleys NHS Foundation Trust said improvements had been made.
On Thursday (1 April), though, a coroner said he was concerned lessons are not being learned.
Just last week, inspectors ruled services at five wards run by the trust were inadequate.
Mina Topley-Bird, the 24-year-old daughter of trip hop pioneer Tricky and singer Martina Topley-Bird, was found hanging at West Park Hospital in Darlington in May 2019.
Mina, who had a history of mental illness, had performed with her band, the 404, in Newcastle days before and was travelling back to her home in London when she became unwell.
The inquest at Redhills in Durham heard she got off the train at Darlington and needed hospital treatment while experiencing a psychotic episode.
A friend who had been with her told the inquest she had tried to run into traffic.
She was assessed at Accident and Emergency at Darlington Memorial Hospital. While there, the inquest heard she had grabbed a pen and tried to stab herself in the neck.
She was transferred to a secure ward at West Park Hospital in Darlington where she received treatment voluntarily. Jurors were told she was not detained under the mental health act.
The inquest heard she had hoped to be transferred to a hospital in London, and was frustrated that no bed was available for her.
Jurors were also told that not all of her information from South London and Maudsley NHS Foundation Trust had been shared with staff at West Park including notes on past hospital admissions and incidents of self-harming.
Coroner James Thompson said he will now write to the Health Secretary about formalising how mental health patients are transferred between hospitals, saying current arrangements were ad hoc.
And he will write to the chief executive of the Tees, Esk and Wear Valley NHS Hospitals Trust, which runs West Park, to raise a number of issues, some of which concerned how medical notes from other trusts were shared.
Elizabeth Moody, director of nursing at Tees, Esk and Wear Valleys NHS Foundation Trust, said: “Our thoughts remain with Mina’s family and friends during this very difficult time.
“We will immediately assess the Coroner’s recommendations and continue to implement further improvements to our services to ensure the safe care of our service users.
“The Trust would also support a national policy relating to the transfer of out-of-area patients, as highlighted by the Coroner.”