The mother of a young woman found dead in a tent at a Lake District beauty spot said her family “sincerely hope” that lessons are learned.
Sarah Lewis said her daughter Callie Lewis was a “spirited, determined and exceptionally intelligent young woman” who was “badly let down”.
An inquest jury concluded on Friday that Callie Lewis died by suicide, which was contributed to by neglect on behalf of an NHS trust, the law firm representing her family said.
A lack of training and knowledge in relation to suicide forums was also cited.
The 24-year-old, from Beckenham, south London, was found dead near Windermere in Cumbria in August 2018, two weeks after being discharged from hospital, the inquest into her death heard.
Jurors at The Archbishop’s Palace, in Maidstone, Kent, were told Miss Lewis had a history of depression and obsessional behaviour, and had autism.
Opening the inquest last week, senior coroner Patricia Harding said Miss Lewis had been sectioned over fears that she intended to take her own life, but was later discharged, and on August 16 was back in the community and in the Dover area.
Ms Harding said: “There was further information which was being received by friends that Callie was still intending to take her own life, and others later learned that she had gone to Windermere, where sadly she was found having died on the 31st August of 2018.”
On Friday the jury concluded that Miss Lewis died by suicide, and that her death was contributed to by neglect on behalf of Kent and Medway NHS and Social Care Partnership Trust, whose care Callie was under in the run-up to her death, the family’s lawyers said.
The jury also found there was a combination of individual and organisational failures amounting to gross failure in relation to Miss Lewis’s care.
Also cited was a lack of training and knowledge in relation to autism and suicide forums, as well as a lack of clarity and consistency regarding recording risk assessments, and a failure to report relevant information.
Speaking after the inquest, Sarah Lewis said: “Callie was a spirited, determined and exceptionally intelligent young woman, who left an impression on everyone who met her.
“She was a much-loved daughter, sister, granddaughter and niece.”
She said that her daughter was “badly let down” by not receiving the treatment, care and intervention she needed.
Mary Mumvuri, executive director of nursing and quality for Kent and Medway NHS and Social Care Partnership Trust, said: “We were deeply saddened by Callie’s tragic death and our thoughts remain with her friends, family and loved ones.
“Following Callie’s death in August 2018, we undertook an investigation to identify areas where we could and should have done better in Callie’s care.
“As a result of the learning, we have significantly improved our systems, processes and procedures of monitoring people who do not attend appointments or disengage from services.
“Earlier this year, we started to roll out a revised comprehensive suicide prevention training for all staff.
“It includes ensuring staff are aware of the needs of people with autism.
“Through the Triangle of Care initiative, we have also improved our working with carers and families and this continues to be an area of focus.
“Nationally there is a drive to increase autism awareness. Here at KMPT, we are developing training alongside people with autism to help embed awareness across the trust.”