A 50-year-old woman's suicide caused by "gross failures" by mental health nurses has provoked improvements at South West London & St George's Mental Health NHS Trust.
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.
An inquest ruled her death could have been prevented if nurses put her on the correct level of observation and read her medical reports properly.
The trust held an internal investigation into the care of Ms O'Connor and has dismissed one nurse, whilst another was subject to disciplinary action.
It said the policy of observation and engagement of patients has been reinforced, with extra training and guidance given on initial emergency procedures.
It also identified the need to improve the communication and recording of issues about patients at a high risk of suicide with the ward consultant.
Staff are also being taught how to book additional support when there are low staffing levels.
A spokesperson for the trust said at the inquest cupboards have been removed from patient's bedrooms and ensuite bathroom doors have been replaced with curtains.
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