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The family of tragic Callie Lewis have issued a statement after an inquest ruled her death a suicide, contributed by neglect.
The 24-year-old's body was found in a tent in Cumbria on August 21, 2018, just over two weeks after she was released from Kent and Medway NHS and Social Care Partnership Trust in Dover.
Ms Lewis, who was born in Chatham, had been sectioned into the mental health centre after a friend told her mother, Sarah Lewis, that she intended to take her own life.
The jury of five men and six women heard evidence over two weeks, and found that her death from Carbon Monoxide poisoning was contributed by a lack of appropriate activity.
The foreman said: "There was a gross failure to provide her with the assistance that she needed, and to follow the correct protocols following a loss of communication with her."
Among other factors, the jury also stated that they believed a 'suicide website' also contributed in some way to Ms Lewis' death.
After the ruling, Senior Coroner Patricia Harding declared she would be making a Regulation 28 report, otherwise known as a prevention of future death report, regarding the site.
"She was a much-loved daughter, sister, grand-daughter and niece" - Sarah Lewis
She said: "[The website] enabled Callie to frustrate the mental health process, and provided her with information regarding the means with which she ended her life.
Ms Harding also declared there would be reviews in due course to ensure changes were made to address the failings that led to Ms Lewis's death.
In a tearful statement to reporters after the ruling, mum Sarah Lewis said: "Callie was a spirited, determined and exceptionally intelligent young woman, who left an impression on everyone who met her.
"She was a much-loved daughter, sister, grand-daughter and niece.
"When Callie became very ill in the summer of 2018 we, Callie's family, desperately sought to ensure she was somewhere she would be safe and could receive the treatment and care she needed.
"We are very grateful to those who listened to us and who took our concerns seriously, including the police officers who sought to keep Callie safe.
"Unfortunately, Callie was then badly let down by not receiving the treatment, care and intervention she needed to keep her safe at this critical time.
"I told every professional I spoke to at the time that Callie would die within the next few days if she did not receive the support she needed.
"I also told them exactly how she would die. I wish I had been believed.
"We, Callie's family, did not know that she had been released into the community, we were not told.
"We sincerely hope that lessons are learnt"- Sarah Lewis
"She did not receive any care at all after her release, and we have heard over the past two weeks of a staggering catalogue of failures by the very people who were supposed to keep our daughter safe.
"By the time the people responsible for her care realised they had lost her, it was already too late.
"I would like to express our thanks to the jury, coroner and all parties for their constructive and thoughtful handling of the past two weeks.
"We sincerely hope that lessons are learnt so that other families do not have to go through what we have had to go through."
For confidential support on an emotional issue, call Samaritans on 116 123 at any time.
