An inquest at Nottingham Coroner’s Court heard this week that Carol Vaughan, 61, who was an informal patient at Millbrook Mental Health Unit in Nottinghamshire, had previously repeatedly self-harmed.  She had been diagnosed with bi-polar disorder and borderline personality disorder.

On 14 January last year, she told staff she was going for a cigarette, but never returned. The inquest heard evidence which indicated that staff did not record her as missing until 40 minutes after she left the ward.

Her daughter, Karen Green, her partner and a police officer later found her in a nearby reservoir and she later died of hypothermia.

Coroner Mairin Casey delivered a narrative verdict and said that there was “no proper consideration of appropriate supervision of the patient when she was allowed off the ward” and “no appropriate record keeping”.

Nottinghamshire Healthcare NHS Trust, which runs the unit, said it had conducted a thorough investigation and “significant changes” had been made.

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