SUICIDAL widow Gillian Sweet killed herself at Green Lane Hospital in Devizes, despite being placed under observations every five minutes, an inquest heard.
Mrs Sweet, 44, of Westcroft, Chippenham, was found unconscious with a bin bag tied over her head on the first anniversary of her mother's death.
A nursing assistant admitted she had only filled in an observation log, designed to record when Mrs Sweet had been checked on, after the patient died.
Coroner David Masters said it was not certain whether Mrs Sweet intended to kill herself or if her actions were a cry for help that went wrong.
He said earlier in the year Mrs Sweet had been found still conscious with a plastic bag over her head. The inquest jury of eight recorded a verdict of misadventure on Wednesday afternoon.
For a week before her death she had been telling staff at Green Lane, where she was being treated for severe depression, she planned to kill herself on the anniversary of her mother's death.
Staff at the hospital, where Mrs Sweet was sectioned under the Mental Health Act, placed her under observations every five minutes because she was suicidal.
The inquest into her death at North Wiltshire Magistrates' Court in Chippenham heard nursing assistant Naz Jondah discovered Mrs Sweet in the en suite bathroom of her room on June 30.
She had a black plastic bag over her head, tied around her neck with a belt which had been stitched to her dress.
Mrs Jondah admitted she had filled in the last three entries on the five minute observation log after Mrs Sweet's death because she had been busy with another task at time. But she said she did carry out the checks.
Staff tried to resuscitate Mrs Sweet using a crash trolley from another ward, but it took four minutes to fetch.
Earlier that day nursing sister Caroline Bennett had taken Mrs Sweet to visit her mother's grave in Calne. She said: "She had talked about killing herself for about a week prior and said she wanted to kill herself on the anniversary. But on that day she seemed quite happy and we had a good time together."
Mr Masters asked Sister Margaret Stone why Mrs Sweet had not been kept in a room with nothing but a mattress.
Mrs Stone said: "We did discuss seclusion but did not feel that it was appropriate for Gill or in her best interests because of her aggression."
She said all potentially harmful items were removed from her room.
Mrs Sweet's sister, Catherine Fenn, of Elder Court, Calne, told the inquest Mrs Sweet had been discharged from the Army after five years on psychological grounds. "Sadly she had a minor breakdown. She started to have bad bouts of depression and heavy drinking," said Mrs Fenn.
Mrs Sweet married her husband Robert in 1988, but he died less than a year later."It was around that time my sister began having treatment for her condition, particularly after her husband's death," she said.
Mrs Fenn said her sister had been badly affected by the death of their mother Margaret on June 30, 1999.
Concluding the inquest, Mr Masters said he would be writing to the Wiltshire Health Authority with his concerns about the filling in of the observation log and his recommendation that crash trolleys should be provided on every ward.
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