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Charity worker Kim Lindfield, 27, (pictured above) had taken 12 overdoses due to severe bouts of depression and repeatedly admitted herself to A&E - but she believed she was ignored and regarded as an attention seeker. She was admitted again with a further overdose but despite her history of self harming and a warning to staff she would ''try it again'', there was no referral for psychiatric help.

 

Hours after her admission to Wythenshawe Hospital, Manchester, Kim was found hanged from a dressing gown cord in her hospital bed by nurses carrying out their rounds - having earlier left her cubicle curtains ajar in the hope of being found. Staff tried to revive Kim but she died six days later after her family agreed to let doctors switch off her life support machine.

 

In the hours before her death, Kim, from Wythenshawe had told a worker: ''there's no point'' when asked what she wanted for tea - but her comment was treated as a remark about the quality of hospital food.

 

At an inquest a coroner recorded a verdict of death by misadventure contributed to by neglect and condemned hospital staff for  ''serious and significant failures.” He said a referral to mental health experts would have saved Kim's life and he branded the hospital's investigation into the tragedy as ''lamentable'' after it emerged some staff on duty at the time of the tragedy were not even asked to give statements.

 

After the hearing Kim's mother Kerry Bentley, 52, a teacher said: ''We have listened to a lack of co-operation and communication, compounded by mismanagement, lack of compassionate care lack of record keeping and a frightening confusion among senior staff regarding the hospital's own policies and procedures.

 

''Unfortunately despite pleading with her many times over the years, Kim did not involve us in her mental health care. Her intention was never to die but she mentioned to friends and counsellors how variable the care would be on visits to the hospital. Sometimes she had a good experience bit sometimes she felt largely ignored and regarded as an attention seeker and time-waster.

 

''No one would regard a patient suffering from cancer or a heart complaint as a nuisance but people suffering mental illness come across attitudes like this all the time. There has been a lot of talk about the need for more compassion in the NHS. We would argue that a person suffering fro mental illness could be deemed to be most in need of this.

 

''From the evidence at the inquest we know there was a catalogue of missed opportunities for psychiatric referral from Kim's arrival at A&E.''

 

The tragedy occurred in July 2012 after Kim who harboured ambitions of becoming a paramedic and was described by her family as ''a beautiful, funny, intelligent, creative and caring young woman'' had been battling mental illness for up to 13 years and had Borderline Personality Disorder which meant she had a fear of ''rejection and abandonment.”    

 

She was a youth volunteer for St John Ambulance and had won a string of awards for dedicated voluntary work including The Princess Diana Memorial Award which is given to young people who unselfishly inspire and improve the lives of others in their communities. 

 

She also won a rotary club award and was honoured with the Grand Prior Award by Princess Anne at Buckingham Palace.  Kim enrolled at Manchester Metropolitan University to study Applied Community Studies but suffered a break down due to the stress of studying and being away.

 

She accessed a charity called 42nd Street so she could get help for her mental health issues and she actively involved in the various youth projects but due to the rules, the counselling service automatically ended when she turned 25 and she was referred to other charities.

 

Despite concerns over her welfare, Kim appeared to rally and moved into a flat in Wythenshawe with her pet cat Molly but her mental condition after being hounded by noisy neighbours. She filed a complaint to housing officials about loud music being played next to her rented flat - but she ended up being labelled a ''grass.'' 

 

After applying  for an alarm to fitted to her home for fear of having intruders, she was admitted to Wythenshawe Hospital on July 17 2012 with a suspected overdose of medication and was allocated bed 27 on Ward 10.

 

Shortly after her admission she told staff she was feeling down and  ''stressed'' about her neighbours. Care support worker Michelle O’Donnell said she spoke to her as she sat in bed and asked if she wanted something for tea only for Kim to reply: ‘There was no point.’

 

Miss O'Donnell said: “I tried to encourage her to have something but she did not want anything. A lot of patients do not really like it and get down in hospital. She did seem sleepy because I did assume she was fed up. A lot of people feel like that in hospital. I mentioned it to a member of staff. 

 

“The nurse asked if everyone had been fed but I said so and so doesn’t want anything. It was nothing out of the ordinary. If someone doesn’t want anything to eat and feels down I will mention to staff nurses. I went outside with Kim. I was asked to take her out for cigarette which is a routine duty. Outside she said she was fed up. She was sick of her neighbours annoying her. She had trouble with her neighbours. She was fed up. 

 

''She couldn’t be bothered anymore. She wanted to do it again and she said she would do it again when she got home. I asked if she had anyone she could talk to. I told the first staff nurse I saw on the ward and whoever it was just said leave it with me.”

 

Patient Leanne Graham said had been speaking to Miss Lindfield in the minutes before the tragedy and said: ''It was pretty mundane conversation really - like she’d been on the ward too long. The last time I saw Kimberley, she was lying on the bed.”

 

Mrs Graham went to the bathroom and noticed the curtains around the bed had been drawn slightly but added: “The only time she knew something serious had happened was when the nurse rushed in and the alarm went off.” 

 

The hearing was told Kim self harmed to ''alleviate stress.'' She had bags packed with clothes for several days an d talked of holidays and returning tom her studies - indicating there was no intention to end her own life.

 

Dr Dinesh Maganty, a consultant forensic psychiatrist at Birmingham NHS who prepared a report on Kim said: ''She  was impulsive and took risks which explains why she had taken overdoses as she was ‘going to the edge’. She was always anticipating that she would be found which explains that on a previous overdose, she remained calm, was extremely helpful to paramedics and had written a list of exactly what she had taken. 

 

“On the day she was admitted no mental health assessment was taken and there was nothing on record. There is absolutely no question that a mental health assessment would have helped. She had no intention of dying.''

 

Manchester coroner Nigel Meadows said hospital staff should have kept records about when Kim should be kept under observation but there was “nothing of note recorded.” 

 

He added: "Kim was a well-loved young woman who suffered from recurrent depressive episodes which led to self-harming to relieve inner tension. She was vulnerable to certain life pressures but there was no evidence to suggest she was contemplating the taking of her own life.

 

''There was a series of significant failures to refer her for a mental health assessment especially as she had attempted an overdose 12 times previously. The fact that she had the curtains closed slightly around her bed suggested that she wanted to be found. 

 

''Observations on Kim should have been increased. It is possible had she been referred as soon as possible for a mental health assessment her life would have been saved or prolonged. "

 

In a statement Dr John Crampton, Medical director at University Hospital of South Manchester NHS Foundation Trust (UHSM), said:  “The Trust would again wish to convey its sincere condolences to the family of Ms Kimberley Lindfield. We are sincerely sorry for their loss and we will cooperate fully with the Coroner’s recommendations to further improve on the changes the Trust has already implemented.

 

“Following the sad death of Ms Lindfield in July 2012, we have been focusing on improving and strengthening our processes for assessing and treating patients with mental health conditions who present to our Emergency Department and who are subsequently admitted to our wards.    

 

“We would like to apologise unreservedly to the family of Ms Lindfield, our hearts go out to them. We would again wish to reiterate our invitation to her family to meet with senior representatives at UHSM if they feel this would be helpful for them.”