Royal Glamorgan Hospital hanging death after risks found
A woman was found hanging in a hospital bathroom eight months after parts of the room were identified as potential ligature points, an inquest heard.
Diedre Harvey, from Tonyrefail, died at the Royal Glamorgan Hospital in Llantrisant in April 2017.
The 52-year-old, who had bipolar disorder, had been sectioned under the the Mental Health Act.
The jury inquest in Pontypridd concluded she had died as a result of an accident contributed to by neglect.
After the hearing, her family said "more could and should have been done to prevent Dee's death".
Eight months prior, staff had carried out an audit of potential ligature points in the hospital. Parts of a lockable bathroom on a mental health ward were identified.
An application for funding was made to the Welsh Government in September 2016 to carry out remedial works, but no action had been taken by the time of Ms Harvey's death.
The potential risks were removed shortly afterwards.
Ms Harvey was sectioned under the Mental Health Act in February 2016.
The inquest heard she had suffered with her mental health since the 1990s, and had previously attempted to take her own life.
Throughout January 2017 her medical records showed that her mood remained low and she repeatedly said she no longer wished to live.
This continued with brief exceptions until she died.
An independent psychiatrist told the inquest the staff were attentive overall, but failed to appreciate how mentally unwell she was and underestimated her degree of risk.
Christopher Woolley, the assistant coroner for South Wales Central, said he would write a report giving guidance on preventing future deaths.
It will focus on what he described as the "fractured nature of her care" and how funding for emergency remedial works is obtained.
In a statement after the inquest, her family said they were still "devastated by the loss of a much-loved mother, sister, aunt and daughter".
They added: "It should not have taken this death for the Cwm Taf University Health Board to remove such an obvious ligature point on the acute mental health ward at the Royal Glamorgan."
Health board chief executive Allison Williams said it was "an extremely sad case and we deeply regret that there were failings" in care.
She said action had been taken to "ensure this will never happen again".