Cornwall Partnership NHS Foundation Trust has been ordered to explain how it is improving its procedures in mental health units following the death of Courtney Smith in February 2017. Miss Smith, 18, died from a paracetamol overdose after unescorted leave from Bodmin Hospital.

Miss Smith had a history of mental health illness and was diagnosed with emotionally unstable personality disorder and complex post-traumatic stress disorder. She was granted an hour a day of unescorted leave in preparation for her discharge from hospital.

The jury were told that Miss Smith would have had time to walk to a local shop where she could have purchased paracetamol. On two occasions she was not searched or correctly signed back into the ward.

Whilst being transferred to Longreach House mental health facility in Redruth Miss Smith was sick. A care assistant found empty pill packets and personal paperwork which outlined Miss Smith’s funeral wishes. This information was not recorded and doctors were not advised. Miss Smith’s condition deteriorated and she was transferred to Royal Cornwall Hospital where she was found to have severe liver failure. She died at a specialist unit in London on 19 February.

The jury recorded an open conclusion and the coroner for Cornwall, Dr Emma Carlyon, told the Cornwall Partnership NHS Foundation Trust to write a letter to Miss Smith’s family explaining how it is changing its procedures, especially regarding its search policy.

Caroline Lody represented Courtney Smith’s mother at the inquest.

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