An inquest has found a woman, who died while trying to abscond from a psychiatric ward, did not intend to take her own life.
Jessica Powell, from Yeovil, Somerset, became trapped in a therapy room window in an apparent attempt to escape from Summerlands Hospital in August 2020.
A jury investigating the death of the 20-year-old ruled that staff failed to adequately supervise and secure the room.
Jane Yeandle, Somerset NHS Foundation Trust’s service group director for mental health, said: “We are very sorry that she died as a result of an incident in our care.”
Miss Powell was awaiting specialist treatment, and was known for previous attempts to abscond.
Her father John Powell told the BBC: “It was just an error of judgement and unfortunately for Jess she just took her chance and that was the way it happened.”
The hospital’s failures included not updating a faulty alarm system which sent staff to the wrong room. Workers were also unable to release Miss Powell because of a lack of access from exterior and interior doors, the inquest ruled.
The jury ruled that staff “failed to adequately supervise and secure the therapy room which was fitted with windows that Miss Powell, a frequent absconder, might reasonably believe she could escape through”.
Miss Powell had been known to mental health services since the age of 16 and was being treated for emotionally unstable personality disorder (EUPD) before eventually being sectioned in October 2019.
The jury at the inquest, sitting in Wells, heard that she was admitted to the Psychiatric Intensive Care Unit in January 2020 because of an escalating pattern of self-harm.
In May 2020, she successfully absconded from the ward through a dining room window, despite that window being fitted with restrictors that should have prevented such an escape.
On the evening of 19 August, staff commenced a search when she failed to collect her medication at about 22:00 BST.
She was discovered with her lower body sticking out of a narrow gap, no bigger than 10cm wide, between 22:30 and 22:40.
The inquest found that the room had been left unlocked, despite her earlier escape attempts.
She died three days later at Yeovil District Hospital. Her primary cause of death being given as an hypoxic brain injury, which is caused by a lack of oxygen.
Mr Powell said that “when she got an idea into her head it was very hard to remove it”.
“When It came to living in the real world, she was just so vulnerable – all she wanted to do was make friends,” he said.
Her sister Lucy added: “She was a very loving auntie, and I miss her every day.”
Ms Yeandle said following Miss Powell’s death, the trust has “commissioned an independent report to look at her care and treatment, the layout of the ward, and to answer her family’s questions”.
“Our thoughts are with Jessica’s family and loved ones. She was loved and intelligent and we are very sorry.
“We look forward to all of the report’s recommendations but will now look closely at the inquest’s conclusion to see if there are further actions we need to take,” she added.