CHANCES to help a popular Barrow pensioner who had attempted suicide twice in a week before she succeeded in taking her own life were missed, a coroner has ruled.

Retired nurse Sandra Theresa Waddington, of Ewan Close, died following an overdose at her home on October 10, 2016.

Assistant coroner for Cumbria, Robert Chapman, concluded the former nurse would still be alive if her family had been informed of the two incidents when she was released from hospital.

He added he could not understand the decision of the mental health team to carry out visits to her every two days, and then three days given the risk she presented to herself.

The inquest, held at Barrow Town Hall, heard the 66-year-old, who had a history of depression, had left a note for her family on September 28 when she had considered stepping in front of a moving vehicle while on unescorted release from Barrow’s acute mental health ward; the Dova Unit.

She had changed her mind at the last minute and informed a nurse on her return.

Just days days later, on October 4, the grandmother took an overdose of prescription medication and was taken to A&E at Furness General Hospital before returning home to receive a visit from the community mental health team, the hearing was told.

But Mr Chapman heard Mrs Waddington’s family had not been informed of her suicide attempts and that despite visiting her they had been unaware of the events that had occurred in the days before her death.

The coroner said: “I can’t understand the change in frequency of visits to two days and three days which is clearly at odds with the risks arising from the incidents of September 28 and October 5.

“I also can’t understand the reluctance to involve the family in the decision with the risks as they stood.”

He added: “If the family had been involved in the discussion I believe the family would have rallied round in order to keep Mrs Waddington safe and she would not have died on October 10.”

Mrs Waddington had been a keen walker and her depression and anxiety had resurfaced for the first time in four years following surgery to her knee earlier in 2016, the court was told.

Raine Marshall, an assistant mental health practitioner for the Cumbria Partnership NHS Foundation Trust, which provides mental health services in the county, had visited her at home when she was discharged from the Dova Unit.

There had been no answer at her home however, and Ms Marshall had posted a note through the letterbox asking Mrs Waddington to call.

That call came sometime later when Mrs Waddington said she had taken an overdose.

Ms Marshall said: “She said she didn’t want to go to the Dova Unit because of the challenging clientele and that it wasn’t a therapeutic environment.

“She had capacity. She was able to make her own decisions about her care. She wanted to be at home.”

Mrs Waddington had denied having further suicidal thoughts and had been deemed ‘low risk’.

Rachel Warwick, a team leader based at the Dova Unit, agreed Mrs Waddington had appeared to be engaging with her recovery plan, was smartly dressed on her departure from the mental health unit and had made plans to see friends and attend the Holy Family Church - all positive signs of recovery.

She added that she had wrongly assumed Mrs Waddington’s family were aware of the attempts she had made upon her own life.

“I knew her family were tremendously supportive and it’s only now that we have come to find what the family knew and didn’t know.”

Mrs Waddington’s two brothers, David Waddington and Paul Waddington, who had both worked in mental health, said they believed their sister’s death had been preventable and that they should have been informed of her attempts.

Speaking at the hearing Paul Waddington, a mental health nurse of 31 years, told the inquest he believed Mrs Waddington’s case should have been escalated quickly.

He said: “You made an assumption that the family were supportive and we were supportive, but what we didn’t know was that she had taken an overdose.

“I believe Sandy was crying out for help and in my opinion she was overlooked.”

Linda Bennetts, associate director of nursing for Cumbria Partnership NHS Foundation Trust, told the inquest the organisation was now in the process of adopting a nationally recognised scheme called the Triangle of Care - which is already up and running in 37 community trusts across the country.

The process puts in place a structure to involve families in the care of their loved ones as they recover from mental illness.

Mrs Waddington leaves her brothers David and Paul, sisters Sue and Stephanie, sons David and Martyn Buzzacott and grandchildren Evie and Paul Buzzacott.

A spokeswoman for the Cumbria Partnership NHS FT said: “Our sincere condolences are with the family of Ms Waddington at this difficult time. We have taken this incident very seriously and conducted a thorough internal investigation. We have listened to what the coroner has had to say and we will be looking at this again in detail to ensure all possible lessons are learned from Ms Waddington’s sad death.”