The Brighton and Hove coroner has demanded action from health chiefs after a patient hanged herself in hospital with a dressing gown cord.
Bethany Tenquist, 26, died earlier this year, 16 days after hanging herself in Mill View Hospital, in Hangleton.
In a report to Sussex Partnership NHS Foundation Trust, which runs Mill View, coroner Veronica Hamilton-Deeley said: “Vulnerable patients are continuing to self-harm.
“The checks which are made and the removal of items which are considered dangerous to patients is clearly incomplete and flawed.
“The example with regard to Bethany Tenquist concerns the fact that on (Saturday) 29 December 2018 when she hanged herself – a short time before she was found, two telephone charging cables were removed from her room yet her dressing gown cord was left available for her to use to hang herself.
“Clearly the system in place to carry out these room checks is unsatisfactory and/or staff are not properly trained to do them.
“Please tell me precisely how you are going to put this right.
“In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action.”
The coroner sent the report in March – after holding two pre-inquest reviews – with the report being made public in the past few weeks by the chief coroner for England and Wales.
It comes weeks after the chief coroner published a letter from assistant coroner Gilva Tisshaw.
She wrote to Sussex Police over the death of David Dooley, who drowned in the sea in Brighton during a storm last October.
Vital time was lost because local officers did not know where to find the seafront lifelines which could have saved the 38-year-old father.
The coroner said: “A lifeline had to be brought from the police station. As a consequence there was a delay in a lifeline being thrown to Mr Dooley.
“There was in fact a lifeline 30 metres from where Mr Dooley’s friend had first alerted the night club security that Mr Dooley was in the sea.
“Steps should be taken to increase police awareness of the location of lifelines and their use so that they can be used more expeditiously.”
