Sasha Forster death: Patient 'let down' by health system
A patient who took her own life while in the care of a mental health hospital was failed by a "flawed" system, her family has said.
Sasha Forster, 20, from Fleet, Hampshire, died in March 2017 while on leave from Farnham Road Hospital in Guildford, Surrey.
The NHS trust caring for her admitted there were "inconsistencies in the care provided".
An inquest jury recorded a finding of suicide caused by an overdose of pills.
Ms Forster, who had severe obsessive compulsive and post traumatic stress disorders, obtained the tablets from a private GP practice, according to the charity Inquest which is supporting her family.
The doctors there were not allowed to access her NHS records, the four-week inquest in Winchester was told.
Hours before her death on 31 March, she was found with the pills by police officers after she had been reported missing, Inquest said.
However the police had no power to detain her because she was on legitimate hospital leave, the charity added.
Surrey and Borders Partnership (SABP) NHS Foundation Trust did not revoke the leave, "leaving her at high risk", Ms Forster's family said.
"We feel that this inquest has shown the flaws and inconsistencies in the system that let her down," they added.
The case had revealed "deeply concerning evidence... [of] failures in care planning and crisis support", Inquest said.
Assistant Coroner David Reid said he would be writing Prevention of Future Deaths reports, although no authority could be said to have caused Ms Forster's death.
He was concerned about doctors' access to vulnerable patients' medical records and a lack of resources to return patients to hospital, he said.
In a statement, SABP trust said: "We have reflected carefully on these events and made several key developments as a result.
"While we gave a lot of care and consideration into how we could... meet Sasha's very complex health needs, there were, nonetheless, some inconsistencies in the care provided.
"We will consider carefully the coroner's report and reflect on what changes in practice may have an impact on preventing future deaths or improving the quality of care."