Suicide observations 'broke down'

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A carer who found a suicidal patient hanging in her psychiatric unit bedroom has described how duties to keep her under observation had broken down.

Sylvan Money, 26, of Presteigne, Powys, had tried to take an overdose in the week before she killed herself.

She died within days of checking into Bronllys Hospital, Brecon, in 2004.

An inquest has heard that a breakdown in the allocation of suicide watch duties meant she may not have been seen for up to an hour before her death.

Miss Money's family had previously told the inquest that she had suffered from chronic depression for many years.

After admitting herself into the psychiatric unit she was initially put under observation every 15 minutes, but that had been downgraded to 30 minute intervals by the time she died.

The coroner, Geraint Williams, had previously spoken of his "incredulity" at hearing how the unit's rota system worked.

The inquest heard that Jane Saunders, a mental health nurse at the unit, had drawn up the rota on the day that Miss Money died.

Mrs Saunders had carried out the first duty and was due to observe Ms Money in the afternoon of the day she died.

She told the inquest that she had been called to a case conference and, although she was in the unit when her duty began, did not carry it out.

Shaun Griffiths, an assistant carer at the unit, had been due to take over at 1500 BST.

But the inquest heard that by 1510 BST nobody had passed on the rota to him, so he automatically took up his duties.

He discovered Miss Money hanging in her room.

He told the inquest: "I saw Sylvan to the left of the window. A chair was at the side of her."

He described how he called for help, and four colleagues had soon arrived at the scene. The court heard that unsuccessful efforts had been made to revive Miss Money.

The inquest is scheduled to run for three weeks.