A 25-year-old woman took her own life after she called a mental health crisis line but an ambulance was not sent to help her.
Jennifer Mary Semple, 25, was found at home by her mum on the evening of August 4, 2019. An inquest was told Jennifer had called a mental health support line at around 5.30am that day.
Senior coroner André Rebello told the court Ms Semple had returned home in the early hours after a night with a friend and became upset. She phoned a crisis line.
Mr Rebello said there was a 'missed opportunity to ensure she was safe' and a 'chance for intervention', reports The Echo.
He said: "It was found that this was a missed opportunity to ensure Jennifer was safe by providing basic intervention to Jennifer, who was in a dependent position of care [and] relying upon the crisis line, in that it was an omission that an emergency ambulance was not asked to attend at Jennifer's home.
"The poor system of the crisis line being operated by a lone worker contributed to this error of judgement."
That evening Ms Semple's mother became concerned for her welfare and let herself into her daughter's house. She found her in the living room.
The inquest heard Ms Semple suffered from poor mental health, with a suspected personality disorder. She had self-harmed in the past. Mr Rebello criticised the level of care offered to Ms Semple prior to her death.
He said: "It was found that the mental health care of Jennifer was not optimal but it cannot be found that these deficits directly caused or contributed to Jennifer's death."
Mr Rebello found that: "There was a delay in Jennifer's clinical care being discussed at the assessment team's multi-disciplinary team meeting. The multi-disciplinary team which took place on 10 July 2019 did not discuss Jennifer's medication and as such was not as effective as it should have been.
"There was a lack of escalation with regards to Jennifer's reports. The clinical service was using historic documentation with the incorrect trust details. Jennifer's anti-depressant medication was not reviewed in line with NICE guidelines."
He recorded a verdict of death by suicide in part contributed to by neglect whilst suffering from poor mental health.
Mr Rebello stressed that the health trust that was in place during the period of time that led up to Ms Semple's death had been replaced with a new organisation. He also stressed that 'lessons had been learned' in relation to Ms Semple's death.
Mr Rebello said that Ms Semple 'should be remembered for her humanity and not for her death.'
