A troubled teenager killed herself during a five-minute gap between hospital suicide checks, an inquest heard.
Sarah-Louise Doyle was found hanged by a support worker at Clock View Hospital, Walton, Liverpool.
The 19-year-old's death has prompted concerns about checks being too predictable, with calls made for collapsible doors in the ensuite area of rooms at the facility.
Sarah-Louise, from Bootle, was described as "kind and quirky" but she struggled with her mental health prior to her death on February 26, reports the Liverpool Echo.
She had been diagnosed with emotionally unstable personality disorder (EUPD) and anorexia and had been sectioned under the Mental Health Act in November last year.
Despite her troubles, Sarah-Louise had been in her third year of a health and social care course at Hugh Baird College and dreamed of working with disabled children, according to her mum Claire Buchanan.
The grieving parent said: "It's hard to put into words but she didn't let her mental health struggles show through. She seemed always happy, she would always help everybody out.
"She was the joker of the family. She loved TikTok, she loved singing and dancing. It's hard to explain it. She was quirky; that is probably the best word."
On December 16 Sarah-Louise was moved to Alt Ward in Clock View, which is run by Mersey Care NHS Foundation Trust. Due to her being deemed a risk of self harm, a hospital worker was required to physically check on her every five minutes.
Andre Rebello, senior coroner for Liverpool and Wirral, described what happened next in a Regulation 28 report, designed to help organisations prevent the risk of future deaths.
He wrote: "On Saturday 26th February 2022 at 9pm a support worker took over responsibility for completing checks on patients as a result of their risk assessment.
"Sarah was on five-minute observations due to a risk of ligaturing. During the five minute checks there were no incidents of note.
"At 9.25pm the support worker went into Sarah's room where she was sat on the bed, replied she was ok when asked and the support worker left the room and closed the door.
"On checking at 9.30pm, the support worker could not see her sat on her bed so went into her and found Sarah [had hanged herself]."
Sarah-Louise was rushed to Aintree Hospital but was pronounced dead at 1.40am on February 27.
Although the full inquest is set to take place later this year, Mr Rebello identified the fact the five minute checks were at regular intervals as a potential risk earlier in the process and sent the report to Mersey Care, Merseyside Police and Sarah-Louise's family.
Mr Rebello suggested that if the patient can accurately predict when a check is going to happen, they may be able to plan a self-harm attempt around it.
He wrote: "On a review of the five minute observations, these were recorded exactly on each five minutes after the hour – 05, 10, 15, 20 etc.
"It will be a matter for evidence to be heard at the inquest whether these times were precise or whether they were written in anticipation of future observations... In other settings it is better practice for five minute observations to be 12 frequent but unpredictable observations within each hour – to minimise the risk of a self-harm attempt being planned from the timing of previous observations."
Concerns about the case were also reflected in reports to the board of Mersey Care, which met on March 29. In the papers, a manager states: "
A 72 Hour Review has been completed and shared with Clinical Commissioning Group and Care Quality Commission and a number of immediate actions identified and undertaken regarding the use and recording of supportive observations, door top alarms and the replacement of ensuite doors with magnetic, collapsible doors."
Mersey Care had identified the lack of door-top alarms, which are activated if a patient tries to hang themselves, as long ago as Summer 2021, according to previous board papers.
Mention is also made of installing anti-ligature bathroom doors in Mersey Care facilities as long ago as December 2020.
A spokesman for Mersey Care NHS Foundation Trust said: “Our thoughts go out to the family and friends of the deceased at such a difficult time.
"Mersey Care remains committed to providing the highest standards of safety for all our patients at all our inpatient units and we are constantly reviewing practices and protocols to ensure that happens.
“We have already implemented a rolling programme of replacing bathroom doors with collapsible doors and to install door top alarms, which is currently being completed at Clock View Hospital and will be extended across inpatient areas across the Trust.
"We pride ourselves on being a learning organisation and we have already carried out a full review of our use of unpredictable observation intervals across the Trust to ensure they are being implemented systematically and without exception."
A full inquest into Sarah-Louise's death is set to take place later this year.
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