The inquest hears Sarah Moore repeatedly told medics she would take her own life if discharged
Sarah Moore was discharged from the Radbourne Unit and her body was found in a park the next dayMental health teams who did not fully consider a patient's risk to their own life "possibly contributed" to her death, an inquest heard.
In his conclusion, Mr Nieto said: "Sarah died… but it is not clear whether she intended to take her own life because she sent messages stating what she intended to do and where she was, implying she wanted to be found and assisted. She told medics she did not want information about her treatment or care plans to be disclosed to her parents, Mr Nieto said.
The inquest heard medics "reached a consensus" that further admission "would not be helpful" to Sarah and her best course was to be sent home for treatment in the community. Ms Moore fled the building about 25 minutes before her discharge time - staff went after her but were advised they "had no power" to keep her on the ward.
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