EIGHT hours after Charles Thorp placed his emotionally fragile wife into the care of mental health specialists she was found hanged by a dressing-gown cord.

Mr Thorp had been assured his wife Elizabeth would be safe when she entered St Martin's Hospital in Canterbury.

But failings in assessment and procedures have now been revealed at an inquest into the death of the 40-year-old mother-of-two.

Her husband, a home security specialist, said this week the judgements made about his wife were fatally flawed. "Now, given the outcome, I just wish I had kept her home with me," he said.

He believes the tragedy was wholly avoidable, because he had told a duty nurse that his wife needed watching closely.

The inquest jury heard that a psychiatrist considered Mrs Thorp to be of "low risk" despite incidents of trying to harm herself shortly before her admission. It meant she was put on hourly observations the lowest level of risk.

The hearing also revealed that vital GP notes on Mrs Thorp were not available to staff, admission paperwork had not been correctly completed and a staff nurse in charge of the ward was wearing a broken watch.

Mr Thorp had sought help for his wife whose depression following an accident near Wingham in which their daughter suffered brain damage had led her to take an overdose, hold a knife to her stomach and try to cut her wrists, all in a 48-hour period.

Her death, more than two years ago, still fills 45-year-old Mr Thorp with disbelief and bitterness even more so now, since the inquest jury returned a verdict of death by misadventure, confirming his view that she did not mean to kill herself.

Speaking after the hearing, Mr Thorp, who runs Sabre Response in Whitstable, said he felt it was the right verdict.

He said: "I knew her previous attempts were cries for help and Liz had said she did not want to leave me or the children. But I believed she was still at risk of harming herself which is why I asked for reassurance from staff that she would be safe.

"Although they say they cannot recall it, I am quite emphatic that I said she needed constant observation because the words are printed in my memory.

"I just cannot understand how someone with a recent history of self harm like Liz can be placed on the lowest level of observations, particularly when they are a new patient to the ward."

He added: "I also think it is very unsatisfactory that a key witness, the nurse in charge on the night, did not actually attend either of the two inquest hearings because she was on holiday on both occasions."

Mr Thorp said his wife's depression was largely brought on by a road accident ten months earlier in which their 13-year-old daughter, Katie had suffered a severe head injury and permanent brain damage.

He said: "When we lived in Wingham, Katie had a friend in Preston and wanted to cycle to see her.

"Liz thought it would safer if she cycled with her so it was something of a cruel irony that as they were coming home that they were hit from behind by a car.

"Katie was obviously the worst hurt and is now at a special residential school, but Liz also suffered a severe leg injury. She wrongly blamed herself for accident but life is full of 'if onlys'.

"Up until the episode of depression which led to her being admitted to hospital she had started to cope quite well and was doing an interior design course at Thanet College."

Mr Thorp now lives in Stonar Gardens in Sandwich with his 16-year-old son, Stewart.

After the jury gave their finding of death by misadvanture, the coronor Rebecca Cobb said: I shall be writing to the trust chief exective to say that I wish him to consider taking action to prevent the re-occurrence of faltalities similar to this."