A series of failures contributed to the suicide of a patient in a psychiatric unit, an inquest found.
Elizabeth Watts was discovered hanged at the NHS Glenbourne mental health unit in Plymouth on January 28 last year.
The 38-year-old nurse, of Appledore in North Devon, had been sectioned under the Mental Health Act after taking an overdose of tablets.
She was suffering from depression deepened by an ongoing Nursing and Midwifery Council misconduct hearing, the inquest heard.
There were widely-publicised allegations that she had sexual intercourse with a patient she took home from A&E in February 2009 while she was working at North Devon District Hospital.
After a four-day inquest into her death, a jury concluded there were a series of problems with procedures which contributed to Miss Watts being able to take her life using shoelaces.
Problems included inappropriate allocation of her room, coupled with staff missing a 15-minute observation at 3.45am. A nursing assistant found her hanged at 4am.
Further defects included incomplete records, lack of clarity regarding roles, lack of a nurse in charge, allocation of tasks, and the shift handover room being in an inappropriate location.
Speaking on behalf of Miss Watt's family after the hearing, clinical negligence specialist Katja Robins said relatives were "very distressed by the loss of a beloved daughter and sister in such tragic and preventable circumstances.
"This is an extremely tragic and disturbing case," said Ms Robins. "The family hopes lessons have been learnt so that this occurrence could be avoided in the future."
Expert witness Dr Dinesh Maganty told the hearing Miss Watts' death could have been prevented that night – but she was at high risk of killing herself in the future.
The leading consultant psychiatrist, who has investigated inpatient suicides for coroners across the country, said: "I have got no doubt there were significant and serious failings in the care she was provided; I don't think there's any denying that."
He said if the 3.45am observation had been carried out, her death might have been prevented, but she could have killed herself within 15 minutes even if the check had happened.
He said there was a failing in staff not assessing Miss Watts further when she became more distressed earlier that night.
He said it was not unusual for a mental health patient to be left with their shoe laces, as staff weigh up whether the removal of such items will cause further distress.
Liz Cooney, deputy chief executive of Plymouth Community Healthcare, told the hearing an internal investigation took place following Miss Watt's death, problems were identified and changes made to address them. A "root cause analysis" had identified 16 issues. Of the four nursing staff working on Bridford ward that night, two were dismissed and two suspended.
Ms Cooney said: "There have been significant changes made to procedure and policies as a result of that event."
Following the hearing, she said: "Plymouth Community Healthcare expresses its sincere condolences to Elizabeth's family for the loss of their daughter.
"We are a caring organisation that strives to give high standards of care to everyone that uses our services."
She said changes made after the internal investigation include "improved patient observation procedure, clearer line management arrangements and ensuring that all staff are absolutely clear on their roles and, most importantly, their responsibilities to the patients in their care".
Police initially investigated the death before the Crown Prosecution Service decided there was no case to answer.
Jury identifies defects in psychiatric unit’s care
Elizabeth Watts’ cause of death was hanging.
She died on January 28, 2011, on Bridford ward, Glenbourne unit, Plymouth.
She took her own life using shoelaces.
There were defects in care provided which contributed to the item being used. These defects were the inappropriate allocation of the room which resulted in her being distant from the staff at a time when she was so vulnerable.
The jury decided this was “exacerbated by the missed observation at 3.45am”.
The jury identified a further seven defects in procedures, which meant Miss Watts was in a position to use the item.
They stated “historically, policies and procedures had not been cascaded down sufficiently to be followed by members of the unit”.
The defects were the missing observation, incomplete records, lack of clarity regarding roles, lack of a nurse in charge, allocation of tasks, the shift handover room being in an inappropriate location and the allocation of her room being unsuitable.