Nottingham: Woman died after walking out of mental health hospital

Helen Tarry's body was found nine and a half hours after she was reported missing from the hospital

A woman died after walking out of a secure mental health facility in Nottinghamshire on Christmas Day, an inquest has heard.

Helen Tarry, an inpatient at the Priory Hospital Arnold, was found dead on farmland in Calverton on 26 December 2022.

The 52-year-old left her secure ward by following a staff member through a usually-locked door.

Failings by the hospital and police led to her death, the inquest found.

Jurors at Nottingham Coroner's Court heard she tampered with a fire alarm and left the premises through doors which subsequently unlocked.

Post-mortem examinations determined that while hypothermia and a cold-induced asthma attack were both possible, the exact cause of her death could not be determined.

The Priory Hospital Arnold was ordered to improve or be closed in January last year

Returning a conclusion of misadventure with a narrative verdict to assistant coroner Fiona Gingell, jurors blamed her death on multiple failings.

This included "communication failures from all parties, inadequate risk management, missed opportunities to mitigate absconsion risk and insufficient senior oversight".

Jurors also ruled there had been "inadequate and confusing record-keeping, missed opportunities to escalate the situation from all parties and a lack of understanding of proper policy and the failure to follow policies that were in place".

Procedures at the hospital, which has been graded as inadequate by the Care Quality Commission, have since been revised, including improvements to staff training and record keeping.

Mirrors have also been installed to help prevent the tailgating of staff through locked doors.

Nottinghamshire Police, which did not dispatch officers to the scene after being notified of Ms Tarry's absconding, also admitted "missed opportunities" during the inquest.

The force said it planned to introduce formalised procedures to prevent similar miscommunications between call handlers and operational staff in future.

'Compassionate and caring'

CCTV showed Ms Tarry had been wearing just a black nightdress, a gilet and slippers as she left the hospital facility.

Her body was found half a mile away, nine and a half hours later.

She was discovered with scratches to her lower legs and feet, and her slippers and gilet missing.

Ms Tarry's partner Howard Mather told the court she was "a beautiful soul", before the jury retired to deliberate for four and a half hours.

"Helen was an absolute angel, who would always bring light into a room. She was incredibly humble," he said.

"Helen was a person who would bring fun and humour, but who was always compassionate and caring."

Her mother Ann Tarry added: "The world seems a colder place without her."