Southern Health failures led to Southampton woman's suicide

Ellie Brabant was left unsupervised for 10 minutes

A number of NHS trust failures led to a woman killing herself after being left alone minutes after an unsuccessful suicide attempt at a psychiatric unit, an inquest has heard.

Ellie Brabant had been a patient at Southern Health Trust's Antelope House in Southampton.

She died in hospital in November last year, three days after hanging herself.

Coroner Grahame Short said a decision to remove a mental health sectioning order also contributed to her death.

He concluded the lack of an adequate care plan during that removal, in September 2017, meant she was able to use drugs while outside of the inpatient mental health unit.

This led to "an inevitable deterioration" of her health, he added.

Since Ms Brabant's death, Southern Health said care at the hospital had been "comprehensively reviewed" and changes made, including employing more staff and installing electronic sensors on bedroom doors.

Mr Short said "significant changes" around observations had since been made by Southern Health.

However, he said he was concerned staff had not been properly trained on the changes and did not fully understand some issues, including safeguarding.

He added Southern Health had also failed to disclose a staff handover, written before Ms Brabant's death, which said she was suicidal. He said he would be alerting police to the matter.

Ms Brabant was a patient at Antelope House in Southampton

The trust apologised in court to Ms Brabant's family, saying: "We're sorry we weren't able to help keep Ellie safe."

The Winchester inquest previously heard Ms Brabant, from Southampton, had been left alone for 10 minutes while nurses discussed increasing the frequency of checks on her.

She was resuscitated by nurses after the first suicide attempt.

The inquest also heard Ms Brabant worked as a prostitute to pay for heroin and crack cocaine while she was living at Antelope House.

In October 2017, a month after the sectioning order was lifted, she lay on rail tracks at Southampton station, forcing a train to make an emergency stop.

Hampshire Constabulary said a prosecution for corporate manslaughter against Southern Health over the case had been considered and rejected, but it added a wider investigation was still under review.

In March, Southern Health was fined £2m after admitting failures in the care of two psychiatric patients.

Connor Sparrowhawk, 18, drowned in Oxford in 2013. Teresa Colvin, 45, died in Hampshire in 2012.

In a statement released by charity Inquest, which offers people support on state-related deaths, Ms Brabant's family said they had been "devastated" by her death.

"The Ellie who took her own life was not the Ellie we knew," the statement continued.

"Although we accept procedural changes have been made following Ellie's death, we do not believe these changes address the fundamental deficiency in Ellie's care.

"We do not feel confident that should another patient like Ellie be under Southern Health's care, anything would be done differently."