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An open verdict has been returned in the inquest of Lauren Ellis, who died at the Oberlands seven years ago.
Lauren had Emotionally Unstable Personality Disorder and died on the Crevichon Ward at the Oberlands Centre on 12 October 2017.
Nurses were supposed to check her every 15 minutes but failed to do so. Official records of the checks that should have been carried out were also found to have been falsified.
Coronial Liaison Officer Phillip Falla reminded the court of the facts of the case, referring to investigations that had revealed two nurses on duty "failed to carry out observations" on Lauren, and that "official records had been falsified".
Those two staff members were later charged with manslaughter by gross negligence but found not guilty by a jurat majority of 7-2 in a criminal Royal Court trial in 2019. Neither has worked for HSC since being charged.
Deputy Judge Graeme McKerrell reminded the court that it was his role to establish the facts surrounding the death, rather than attribute blame to any party.
But he did say that "the reality was no checks were conducted for a period of time" and "there is no hiding that checks on Lauren should've occurred but did not".
He returned an open verdict because there are certain genuine cases where "there is real doubt in respect of each possible verdict, and any verdict other than open would be unjust".
He acknowledged there had been significant delays between the opening and resumption of the inquest, and said he hoped some relief can now be brought to her family and friends.
"It is difficult to comprehend why it has taken so long overall," he said.
Lauren's mother, Dawn Ellis, read a statement to the court surrounded by family, noting it had been 2,260 days since her daughter passed away.
She said Lauren was "well known to doctors and nurses at the PEH and the team at Oberlands", and she had been assured by a nurse on duty that she would be well cared for after becoming concerned about her condition following an hour-long phone call the night she died.
"There had been an escalation in the self-harming... which resulted in Lauren agreeing to attend Oberlands so that she could get some rest in a safe and secure environment."
The criminal investigation and learning that "police were so concerned that arrests were made" was "unbearable" for the family, especially since there were multiple failings in Lauren's care which has affected them all "terribly".
"15-minute observations were not carried out... We have since become aware of other failings such as the machinery that was used to try to clear Lauren's airways was faulty, doors were locked preventing emergency access, the wrong number was dialled when the ambulance was called resulting in another delay in emergency care.
"We will always feel the individual and collective failings of the hospital contributed to us losing her."
Prior to her death she had been saving up for a holiday with family and friends, while also "making plans for her future", her mother added.
"She had a huge personality... we will never have closure... the delay has kept the pain very raw... we all miss her so much."
Her death triggered a review into local mental health services, and Mrs Ellis hopes that "findings from this review have been fully implemented to avoid other families suffering in this way".
Samaritans are here - day or night, 365 days a year. You can call them for free on 116 123, email them at jo@samaritans.org, or visit www.samaritans.org to find your nearest branch.
"Lauren has been let down again"
Review of mental health services underway
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