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A woman who was found dead at a mental health hospital after saying she was going to take her own life "wouldn't have died" if nurses had checked on her more often, an inquest has heard.
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.
Previously the inquest had heard that in the days before her death Ms Pring had been found by staff on three consecutive nights - from April 14 to April 16 - with ligature around her neck and was expressing suicidal and self-harm ideations.
Before the jury, made up of six female jurors and four male, was sent out it heard from Cygnet's quality assurance and service development officer Megan Johnston who outlined a number of changes which have been made since Ms Pring's death.
Ms Johnston explained a root cause analysis (RCA) had been done by an independent Cygnet employee from another hospital.
The RCA revealed that nurses observing Ms Pring didn't increase the amount they were checking on her, despite incidents the previous week, and that it's likely she "wouldn't have died if observation increased".
'Emma was a loyal and generous person...'
Tom Stoat, representing Ms Pring's family, explained how evidence from one of the nurses observing her on the night she died detailed how a partially filled out handover sheet meant she didn't know the level of risk surrounding Ms Pring or why she was being observed.
When questioned on whether paperwork was checked by senior members of staff Ms Johnston explained a monthly audit of four samples of paperwork was checked and were 90% compliant.
Coroner Catherine Wood heard evidence about the hospital's use of "anti-tear" clothing which was given to inpatients.
It was explained how any clothing given to patients was now checked before being handed out and after being washed for any damage, and that the style of trousers which Ms Pring was wearing the night she died were removed from all Cygnet hospitals.
Mr Stoat expressed the family's concerns that they, as well as Ms Pring's lead practitioner Mark Oldham, were not told about the events from April 14 to April 16, which were cause for concern.
Ms Johnston explained that as the patient had not been injured and did not require hospital treatment the incident wasn't deemed "serious", which is when family and other close parties would be informed.
Last week jurors heard Ms Pring's mother, Caroline Sharp, describe her daughter as a "ray of light" and a "loyal and generous person who puts others first".
The family also said she had "an infectious smile and laugh".
The jury is set to return tomorrow morning to deliver its verdict.
For more information on how we can report on inquests, click here.
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