THE heartbroken husband of a mentally ill woman who died while being looked after at a mental health unit in Redditch has said he hopes lessons will be learned from the tragedy.

43-year-old Clare Ineson from Hollywood was an in-patient on Hill Crest Ward, adjacent to the town's Alexandra Hospital.

She was admitted to the unit on November 22 last year having been considered to be a suicide risk.

A recent inquest into the mother's death heard that on admission Clare was placed on observations every 15 minutes.

Clare was advised to approach a member of staff if she felt unsafe and on the evening of November 27 she did just that.

However, the conversation and reassurance she sought never took place as the member of staff she approached was observing another patient at the time.

There was no attempt by that member of staff to engage with her later during that evening or to request another member of staff speak to her.

During the early hours of November 28 Clare was found to have severely harmed herself - with items that had not been removed from her possession.

She was transferred to the local intensive treatment unit at the Alex Hospital but was unable to recover and died on December 3.

The jury at the inquest identified a number of damning failures of Worcestershire Health and Care NHS Trust, which runs Hill Crest.

These included inadequate risk assessments during admission, observation levels that did not appear to reflect the patient’s presentation and inadequate engagement and care by nursing and healthcare assistants during the admission.

The jury further commented that, given that Clare was known to be an intensely private person, any opportunity for engagement initiated by her should have been followed up in a timely fashion, adding that this and several missed opportunities such as an absence of clear strategy on potentially harmful possessions and objects, may have contributed to her death.

Husband Nigel Hinks said: “The death of Clare has had a devastating effect on me and our family

“I am satisfied with the outcome of the inquest and the jury’s findings very much mirror the concerns I have had since my wife’s death.

"All I have ever sought from the trust is an apology and reassurance that steps will be taken to ensure that what happened to my wife cannot happen to anyone else."

The jury at the inquest, at Worcestershire Coroner Coroners, returned a narrative conclusion.

The coroner also issued the trust with a report to prevent future deaths.

A spokesman from Worcestershire Health and Care NHS Trust said: “The trust continues to offer its condolences to Clare’s family and we are in contact with her husband during what we know is an extremely distressing and upsetting time.

"Following the jury’s conclusion we have received recommendations from the coroner to review some of our processes and procedures on the ward which is currently being done.

"It is right that we are thorough in our review of current policies and procedures to help prevent a future incident of this kind in any of our mental health wards."

They added: "It would be inappropriate for us to comment further until this work is complete and until our response to the Coroner’s recommendations are finalised.”