SYLVAN MONEY'S family were relieved when she was admitted to Bronllys Hospital, near Brecon, in January 2004.
The 26-year-old artist had taken an overdose the week before; her family had struggled to get treatment for her after they were informed by a hospital in Hereford that they could not treat her because she did not live inside its geographical catchment area.
But less than a week later, Ms Money was dead, having hanged herself from a curtain rail that staff at the hospital were convinced could not be used as a ligature point.
Powys coroner Geraint Williams yesterday detailed a series of "catastrophic failure" in procedures - noting 36 points in all - at the adult mental illness unit at the hospital.
After the inquest yesterday, her parents Christopher Money and Carol Horne said, "We are still filled with overwhelming grief and desperation for ever admitting Sylvan into such an environment.
"We thought she was safe and would be looked after. But if we had not done that, she would still be here today.
"We are Sylvan's voice now.
The three-week inquest into her death ended yesterday, with a verdict that failings at the hospital had amounted to gross neglect and had contributed to Ms Money's death.
Mr Williams said, "Sylvan's death was contributed to by a catastrophic failure of the system at the adult psychiatric unit at Bronllys Hospital."
The key failure was a breakdown of the rota system designed to ensure patients considered at-risk were monitored at regular intervals.
He also criticised the fact that many of the staff at the unit had received no training in carrying out observation duties.
Sylvan's father said, "From the outset when Sylvan died, there was no contact between the hospital and ourselves.
"Nobody from the hospital informed us of Sylvan's death, we found out from one another or from the police.
"We were all left absolutely on our own without any support. That memory will stay with me forever."
Many staff members were unaware that one colleague had learning difficulties and was unable to read guidance notes.
Other deficiencies included:
A general attitude among many staffthat there was no need to inform anyone if they could not carry out their hourly suicide-watch duties;
No one taking responsibility for monitoring the situation which meant such failures were never detected;
A lack of structure to the way information was passed on to staff, with records not properly kept and many staff not appearing to have read patient files;
Staff not spending enough time with Sylvan and not carrying out daily reviews of suicide watch frequency;
Senior staff failing to carry out obligations to provide a safe environment;
A report instructing the hospital to check for potential ligature points being passed on to a department which then ignored or forgot it for almost 18 months;
Senior staff members believing curtain and other rails at the unit had been made safe or collapsible, to prevent them being used as ligature points, when that was not the case, and
The person responsible for passing on official danger and warning bulletins being untrained and inexperienced.
Last night, Gillian Todd, the medical director of the Powys Local Health Board, issued a statement expressing her determination to correct the problems addressed by the inquest.
She said, "Whilst awaiting the conclusion of the police and coroner's investigations, the LHB undertook considerable work to address the many issues identified through the case.
"This work has included revising policies, improved record keeping, audit, staff training, preventative maintenance and ensuring that there are proper procedures relating to the receipt and implementation of hazard warning notices. This activity is kept under constant review."
The LHB also carried out an interim report into the incident.
It concluded, "The patient was a seriously ill young woman.
"The overall conclusion is that the care she received was uncoordinated, poorly documented and provided in an environment which was not compliant with best practice or extant guidance.
"All of these factors and the lack of compliance with policies and procedures led to sub-optimal care."
The inquest heard a consultant authorised lengthening the gaps between staff monitoring Sylvan, without having consulted case notes.
Mr Williams said, "I'm staggered that a consultant would countenance such a course of action without asking to see the notes [taken by a colleague in an interview with Ms Money], given that Sylvan was a new patient and that [the consultant] himself felt that more was going on."
