A prevention of future deaths report has been issued to a textiles company after a young woman killed herself while staying at a mental health hospital.

Emma Pring, 29, was receiving trauma therapy at the Cygnet Hospital in Weavering, Maidstone, when she died as a result of asphyxiation on April 20 last year.

The former nursery nurse had a long and complex history of mental health problems - including emotionally unstable personality disorder (EUPD) and post-traumatic stress disorder - after she was the victim of two sexual assaults when she was 18 and 19.

A seven-day jury inquest concluded Ms Pring died as a result of hospital failures involving “anti-ligature” clothing she had been wearing.

Now, a prevention of future deaths report from coroner Catherine Wood to textiles company Interweave - who created the clothing - has been made public.

It says the clothing was commonly referred to as “anti-ligature”, “safety clothing”, or “seclusion wear” which may have provided some reassurance to clinical staff that ligatures could not be made.

The report also said Ms Pring managed to create a fatal ligature from the clothing and that since Interweave were notified of her death they have made “considerable” efforts to reduce the risk of self-harm with their garments.

It continued, stating some of the products like the Maidstone patient had worn are still in circulation and risks remain in place, even more so after the coverage of Ms Pring’s death.

The inquest heard evidence that around 5,000 anti-ligature garments of the same design issued to Ms Pring remain in circulation in various detention settings such as NHS hospitals, private hospitals and prisons, without information provided to those still using them, or any recall notice having been issued.

The coroner is considering whether to issue a further report about the lack of national standards in relation to the manufacture of anti-ligature clothing in the UK.

Tara Mulcair of Birnberg Peirce solicitors, who represented Ms Pring’s family, said: “Emma’s family welcome the coroner’s decision to issue a Prevention of Future Deaths report to Interweave.

“The report reflects Emma’s family’s serious concerns that thousands of the anti-ligature garments of the same design worn by Emma are still in circulation and being provided to the most vulnerable in society.

“Interweave must now take urgent steps to notify their customers of the risk to life posed by these garments.”

During the seven-day inquest the court heard how in the week before her death Ms Pring had been found on three consecutive nights with a ligature around her neck and was expressing suicidal and self-harm ideations, just days after being placed on “prolonged exposure therapy” which involved her reliving the horrific experiences of being raped as a teen.

Towards the end of the hearing, the inquest heard a root cause analysis completed after Ms Pring’s death by an independent Cygnet member of staff said she “wouldn’t have died if observation had been increased” after the incidents in the week before her death.

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