Inquest told that Caister woman’s death by hanging could have been prevented

A four-day inquest has found that a Caister woman's death by hanging while in hospital could have been prevented if Norfolk's mental health trust had not been guilty of 'serious failings'.

Louise Noon, 24, from Caister, suffered from bipolar affective disorder and died at Great Yarmouth's Northgate Hospital on July 23 last year.

A four-day Norwich inquest, which ended today, heard that Miss Noon was admitted to the hospital run by Norfolk and Waveney Mental Health Trust, on June 30 after she took an overdose.

Miss Noon was detained under the Mental Health Act on July 20, after taking another overdose, but observation of her was twice reduced in the following days, from six times an hour to two times an hour.

No written records were kept of why the observation times were changed, which was against the trust's policy.

Returning a verdict of suicide while suffering from a mental disorder, the jury said: 'Had the risk assessment process been completed with integrity, the means by which Louise met her untimely death would not have been available to her.

'From the evidence heard there does appear to be an inadequately defined process of risk assessment, care planning, treatment records and handover notes or a recommended standard of completion of these documents that are vital to the continuity of patient care.'

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Afterwards, Louise's mum Claire Noon said the family was satisfied with the verdict and the jury's answers to questions put to it regarding Miss Noon's care.

During the inquest, Mike Lozano, the trust's complaints manager, said changes had been introduced after Miss Noon's death, and said staff at Northgate had been given specific internal training to raise their awareness of the trust's policy.

See the EDP and Norwich Evening News tomorrow and the Great Yarmouth Mercury next Friday for a full report.

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