A woman's suicide could have been prevented if mental health nurses had not committed "gross failures"

Julia O' Connor, of Mortlake, hanged herself while she was a patient in Queen Mary's Hospital, Roehampton Lane, after being transferred the day before from Kingston Hospital.

A nurse has been dismissed since her death and another suspended for neglecting to put her on the right level of observation.

Westminster Coroner's Court heard on Wednesday that Mrs O' Connor had a history of mental illness and was paranoid about going to prison for benefit fraud.

She was informally admitted to Lavender Ward, Queen Mary's Hospital in December 2010, where she was receiving treatment for depression.

On March 14 last year she decided she wanted to leave and was visited at home by staff instead.

But five days later she overdosed on prescribed medicine, paracetamol and alcohol and was sent to Kingston Hospital.

Whilst receiving treatment she was overheard saying she would hang herself by staff and by her long-term partner Andrew Swaddon.

She walked out of the ward on March 19, returning three hours later after Mr Swaddon found her at home.

At 11pm that night she was transferred to Queen Mary's Hospital, but a lack of staff meant she had to make her own way there.

The online system was down so nurse in charge Lynda Ellerton could not access her records and neglected to give her a risk assessment, meaning she was only checked hourly.

Nurse Edward Safo took over the next day and neglected to read Mrs O'Connor's hospital records.

At 8.34pm that evening he found Mrs O'Connor in her room less than an hour after she had last been checked.

He performed cardiac massage with the help of hospital staff, but she was pronounced dead at the scene.

Mr Safo was dismissed from his job four months after her death, but complained the hospital was under staffed and is appealing the decision.

He said: "I think I was in a difficult situation - there were only two nurses. I think it was a serious failure, I think there was more that I could have done.

"I think she should have been on level two observation with one-to-one contact."

An inquiry held by South West London and St George’s Mental Health NHS Trust has resulted in cupboards being removed from patient's bedrooms and the door to ensuite bathrooms replaced with a curtain.

Coroner Dr Fiona Wilcox criticised staff for transferring Mrs O' Connor alone so late in the evening and for not giving her thorough observation.

She said: "This is a gross failure and plain as a pike staff she should have been observed on levels two and three.

"This was a preventable death caused by neglect of staff nurses who placed her on the wrong level of observation.

"If she was placed on the right observation she would not have taken her own life at the time she died. It is a tragedy that her illness caused her so many troubles."