A physiotherapist was found dead in a burning car a day after she was given a day pass from a psychiatric hospital.
Yvonne Robson had tried to take her own life the day before she walked out of Hairmyres Hospital and drove to Ayrshire where her body was found the following day.
The 51-year-old had a long history of mental illness in the years before her death a Fatal Accident Inquiry (FAI) at Hamilton Sheriff Court heard.
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And in the months before the tragedy the East Kilbride woman spent a significant time in hospital, a report into the circumstances published earlier this month explained: "Her first admission to hospital was in 1989 with a diagnosis of manic depression or bi-polar affective disorder.
"She had attempted suicide on several occasions.
"There were also periods when Ms Robson was able to maintain both employment and relationships."
Ms Robson was admitted to hospital again in late 2014 following another attempted suicide and later discharged into the care of NHS Lanarkshire's community-based psychiatric team.
But her condition escalated amid further fears she would self-harm and she was re-admitted to ward 20 at Hairmyres Hospital as a voluntary patient two days before Christmas with a diagnosis of Bipolar Affective Disorder, severe depression, and suicidal ideation.
She was given 12 Electro Convulsive Therapy (ECT) treatments between January and February, but the inquiry heard that no mental state examination was carried out at the end.
One of the doctors responsible for Ms Robson's care was not aware of guidance recommending that "patients who are depressed enough to have ECT should be advised not to drive for three months after recovery because this is the law. They may be advised that this is because of the nature of their depression not because of ECT.
"Given that ECT may bring about a more rapid remission they may be driving again more quickly if they have ECT than if they don’t”.
Ms Robson, who was also unaware of the advice on driving after ECT, had her drug regime changed, followed by a delay in her new prescription, which was never explained.
By March her doctor believed the ECT had been reasonably successful and they met on various occasions in March and April when it was noted that Ms Robson "had signs of depression, a reduction in suicidal thoughts, difficulties with medication but increased anxiety, with anxiety escalating".
Ms Robson's care was handed over to a different doctor in late April and they met several times until mid-May.
The inquiry was told that at one point after the meeting, Ms Robson requested that hospital staff did not contact family members for various reasons, although there was no written record. This resulted in a lack of communication with the family.
Ms Robson was issued with several passes allowing her to be absent from the ward as part of her discharge strategy.
On May 21 a very distressed Ms Robson was out on a pass when she called her brother, a GP, telling him she had taken an overdose and been sick.
Unable to drive himself at the time and confident she did not need an ambulance, he stayed on the phone with her while she drove back to hospital and spoke to a member of staff to request that his sister not be allowed out on a further pass and that he be given regular updates about her condition.
Despite being assured this would be taken care of, Mr Robson left the hospital the following day on another pass. She was found dead on May 23 by passersby, her Honda Jazz still alight on a quiet road near the Carrick Hills outside Maybole, Ayrshire.
Sheriff Millar, who presided over the inquiry found there were several instances where Ms Robson's care was "less than ideal", including a delay in obtaining psychological input and a failure to record family concerns.
He said consultants acted in her "best interests" during her time on ward 20, but went on to point out: "The circumstances of May 22 were described as a perfect storm, the consultant was not working that day, she had no access to medical records, she was advised of the overdose when phoning about another patient and while at hospital with her own child, Ms Robson was seen by a junior locum doctor who had not started her psychiatric training and who described her prior involvement as a scribe, not diagnosing patients, not even prescribing medication without supervision, accompanied by a staff nurse not experienced in that ward and confusion over the actual communication and advise given."
He went on: "Any advice actually given by the consultant was not recorded. According to her evidence, that was that Ms Robson was to be kept in overnight, physically and mentally assessed the following day, and allowed to go on pass if she wished. There was no such assessment properly carried out. In summary, the pass should have been cancelled and, if not, the family should have been advised in advance, and Ms Robson should not have been driving. These would have been reasonable precautions."
Failures in Ms Robson's care were previously identified at a significant adverse event review and key findings and recommendations made.
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