Maria Duarte inquest: Mental health patient 'failed' by Southern Health

Maria Duarte, known as Joey, was admitted to Antelope House in Southampton in 2017

A mental health patient who took her own life was "failed" by an NHS trust, her family has said.

Maria Duarte, 49, known as Joey, was found hanged in her room Antelope House, Southampton, run by Southern Health NHS Trust, on 19 January 2018.

An inquest found she was being checked hourly, and staff "missed opportunities" to review her care.

The trust said it had implemented "meaningful and ongoing changes" as a result.

The inquest at Winchester Coroner's Court heard Mrs Duarte had had mental health problems over two decades.

She had twice been admitted to Antelope House as a voluntary inpatient after taking several overdoses of her anti-depressant medication.

Southern Health said changes had been introduced ay Antelope House in Southampton

The day before she killed herself, the inquest heard Mrs Duarte had threatened to harm herself with a plastic knife, had talked about jumping off the roof of Ikea and overturned a table in frustration.

After giving her Lorazepam to settle her down, staff said they did not feel they needed to increase her observation and she was checked every hour, rather than the 15 minute check for high-risk patients.

Cries for help

The coroner said he felt Mrs Duarte's mental state had been altered by changes to her medication - and it would have been helpful if her family had been involved in those discussions to give her more support.

Following the inquest her husband Marco said: "Joey had so many cries for help and they missed all those cries.

"I really feel they failed us and they failed Jo, they failed our family. We will miss her forever."

Lynne Hunt, chair of board of South Health, said: "Our own investigations and the coroner's conclusions revealed missed opportunities.

"Joey's death has led to meaningful and ongoing changes to make Antelope House, and indeed all our whole trust, a safer place."

An independent investigation in the wake of the deaths of Ms Duarte and another patient Ellie Brabant, made recommendations that risk assessments and observations involve families more closely. Patients are now checked at least every 30 minutes.