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A coroner admits she is "concerned about future deaths" after a troubled mum-of-two took a fatal overdose just a day after being ruled safe to return home from a mental health unit.
A psychiatrist discharged Clair Rigden, from Canterbury, despite her having made two attempts to take her own life in the weeks before.
It has emerged the doctor who sanctioned her release had also not been made aware of fears raised by the 37-year-old's family that she would harm herself if discharged - because the concerns were not logged by staff until two days after she overdosed.
Speaking at an inquest into her death, her mother, Tina Rigden, says her daughter would still be alive if she had not been sent home by doctors.
“I feel so let down by the care system,” she said.
“It severely let my daughter down and she would still be alive today if they had sectioned her.
“My daughter lived for her children. She needed a stable place to be.
“She was clearly not of sound mind, she felt totally misunderstood.
"Now as a parent I have to live with the fact that I brought her home to kill herself" - Tina Rigden
“Now as a parent I have to live with the fact that I brought her home to kill herself.”
Ms Rigden, who had a personality disorder and was hearing voices in her head, first overdosed in March 2017 and was in intensive care before being sent to St Martin’s Hospital in Canterbury for psychiatric treatment.
On the day she was discharged - March 31 - she took another overdose and again spent time in intensive care at Kent & Canterbury Hospital.
On April 3 she was transferred to the Priority House mental health unit at Maidstone Hospital.
She told doctors she was certain she would overdose again, but following risk assessments was released from the ward on April 7 after staff noted an improvement in her state of mind.
On the day of her release, her mother noticed blood on her arms from self-harming and raised serious concerns about her being discharged, but she was still sent home.
The following day, on April 8, Ms Rigden overdosed on prescription drugs and was found by her mother unconscious on the sofa at her home in Knight Avenue, Canterbury.
She had left suicide notes to her two children.
She was rushed to hospital, but died from pneumonia and multiple organ failure on April 11.
The inquest was told her mother’s concerns about discharging her were not documented until April 10 and not seen by psychiatrist Dr Alison Puffett, who sanctioned her release.
Following a four-day inquest in Maidstone, assistant coroner Sonia Hayes ruled Ms Rigden’s death a suicide.
A spokesman for Kent and Medway NHS and Social Care Partnership Trust (KMPT), which runs Priority House described Ms Rigden’s death as “a tragedy”.
“Our deepest sympathies remain with Clair’s family and all those who loved her,” he added.
“We listen carefully to HM Coroners’ feedback from inquests and ensure that where action needs to be taken, or improvements made, this is done and the changes made, sustained.”
Anyone in need of emotional support is urged to call the Samaritans on 116 123. Kent County Council's Release the Pressure campaign also urges people to call 0800 107 0160 where support is available from trained and experienced mental health staff, 24 hours a day 365 days a year.