Gross failings at a mental health unit contributed to the death of a patient who died after jumping in front of a train, an inquest has found.

Troubled mother Natalie Gray discharged herself from Priority House, where she was receiving care on a voluntary basis, and made her way to Barming railway station in April last year.

There she took her own life, around three hours after leaving the ward.

The 24-year-old, from Folkestone, had a long history of mental health difficulties and was under the care of mental health services after attempting suicide several times.

Today, after hearing three weeks of evidence, a jury of four men and seven women concluded negligence by Kent and Medway NHS and Social Care Partnership Trust had played a part in Miss Gray’s tragic death.

They found there had been insufficient risk assessments carried out regarding her mental state, and that staff handovers between shifts had been inadequate.

The night before Miss Gray’s death she had been suicidal, and a doctor decided she should be reassessed if she became agitated and tried to leave the unit, although the inquest heard this was not passed on to all staff.

At around 3pm on the day of her death, Miss Gray became very distressed and expressed a wish to end it all.

After an occupational therapist had allowed her out of the Hermitage Lane unit, staff delayed looking for her and contacting the police, who had no patrols available to begin a search, the inquest heard.

Miss Gray died just a mile away, around three hours later.

The jury found there had also been failures to convey and enforce procedures for when informal patients wanted to leave, and that occupational therapists had failed to follow them.

The inquest also concluded the NHS trust had breached policy by not contacting next of kin and the deputy ward manager had failed to provide police with relevant information, for instance that Miss Gray had been suicidal when she left the unit.

The jury also noted that the 999 call taker and back-up police dispatch officer at Kent Police had failed to elicit the relevant information from the trust.

Following the inquest Miss Gray’s aunt Roselin Sayer said: “Losing Natalie has left an enormous hole in our family. It has been a fight every step of the way to get to the truth of what happened to her.

"We hope that lessons will be learned from Natalie’s case and that Priority House will take steps to prevent future deaths by conducting proper risk assessments and improving procedures for allowing patients off the wards to ensure that no other family has to go through this."

Senior coroner for mid Kent and Medway, Patricia Harding, is set to publish a report detailing action to prevent future deaths.

If you would like confidential support on an emotional issue, call Samaritans on 116 123 at any time.