A mentally ill mother walked out of a Kingston Hospital psychiatric bay where staff were meant to be monitoring her and took a fatal drug overdose, an inquest heard.

Janine-Marie Linder, 44, was suffering from severe depressive disorder when she was taken to hospital by ambulance on June 5, 2014, after claiming to have taken an overdose.

She had a history of mental illness and told hospital staff that she thought people wanted to hurt her and her daughter.

She was put in a monitoring bay in the emergency department but was allowed to walk out unchallenged and, that night, overdosed on drugs.

Her internal organs shut down and she was transferred to a specialist unit department at Kings College Hospital, where she died on July 20.

Specialist mental health adviser David Bagott said: “It seems she asked to go out for fresh air and then left the hospital. The cubicle [she was put in] could be better.

"We are working with Kingston Hospital to ensure that the room is of standard.”

At Ms Linder’s inquest on Wednesday, West London Coroner’s Court heard that the local mental health assessment team misunderstood how severely ill Ms Linder was. 

No member of the team saw her before the overdose, despite her Hook Surgery GP Toyin Baikie making an urgent request for a visit in April 2014.

Ian Higgins, who helped investigate the events leading up to Ms Linder’s death for South West London and St George’s mental health trust, said: “The communication from the mental health team back to the GP could have been better.

The initial referral was received on April 10. There were problems with engagement and being able to see her.”

As well as her depressive disorder the court heard Ms Linder was a hoarder and her home, in Frimley Road, Chessington, had no working toilet or heating.

Kingston mental health team had managed to make contact with Ms Linder over the phone but she was unwilling to let them into her home chaotic house.

Dr Higgins said: “I think the assessment and phone contact was appropriate.

"The best practice with hindsight would have been to go back to GP Baikie [who Ms Linder was familiar with] to confirm, ‘This is where we are’.”

He added that since Ms Linder’s death policies had been reviewed and there were now “quarterly audits [to monitor] risk and how risk is managed” plus more regular contact with GPs.

Ms Linder’s daughter, Eleanor Fitzgibbon, who lives in Manchester, said money worries and the death of her grandmother in 2006 were contributing factors in her mother’s depression.

She said: “She was a quiet person. We don’t want to blame anyone, we just don’t know what happened. I don’t think she was capable at that point of thinking things through.”

South West London coroner Chinyere Inyama ruled Ms Linder died from suicide while suffering from severe depressive disorder with psychotic delusions.