A woman sectioned under the mental health act died after self-harming in her home - where she was receiving 24-hour supervision, an inquest heard.
Claire Morris, 35, had been granted leave from a mental health unit in south Manchester, when she was found critically injured in her bedroom by staff on December 15, 2020.
She was rushed to Manchester Royal Infirmary where despite the best efforts of hospital staff, she was pronounced dead a short time later.
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A jury at Manchester Coroner's Court heard that Ms Morris had been under the care of Jigsaw Mental Health Facility in Didsbury, after being diagnosed with unstable personality disorder as a teenager.
In the summer of 2020, Ms Morris was granted Section 17 leave, which allowed her to return to her flat in Wythenshawe - where she would be supervised by mental health staff 24 hours a day.
Jurors heard that Ms Morris, who suffered with anxiety and had a history of self-harm, had expressed multiple concerns about changes to her nursing team in the lead up to her death.
Despite her history of self-harm, the court heard there was nothing written in her care policy about how often she should be checked on by staff.
Further risk-assessments about Ms Morris' risk of self-harm which 'should have been' completed, were not done so in the months leading up to her death, the court also heard.
On the night of her death, she had been on the phone to her mum, Janet Le Boutillier and had been making arrangements for Christmas, the court heard.
Ms Le Boutillier said: "She said she would not be able to come that year because a member of staff had been rota'd to be with her for Christmas Day who didn't' celebrate it.
"She didn't want to upset that staff member by bringing her along. Claire said she'd ask the hospital if anyone else was available but she was told they weren't.
"She loved Christmas and was annoyed at the way things were going. I promised I would phone the hospital the next morning. I had no concerns about her and we had actually arranged to go shopping the next day."
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Following Ms Morris' tragic death, Ms Le Boutillier described her daughter as a 'happy-go-lucky' woman who loved singing and cooking, and adored her two cats Angel and Socks.
"She didn't have much of a teenage life because of her illness so she tried to fit it all in as she got older," she said. "She loved her cats; they were her everything.
"To begin with, she was very happy with the set up at Jigsaw. She had been given a new flat near to the hospital and she was happy with her care plan.
"The last couple of months of her life it all changed. The staff she had come to rely on started changing and she got very upset because was very uncomfortable with change."
Ms Le Boutillier said she would usually speak to her daughter over the phone, as due to the ongoing coronavirus pandemic, Ms Morris was worried about passing anything on to her mother.
"She phoned me on many occasions upset and I would tell her to call the hospital and she said she had many times but that she was getting nowhere," she said.
Ms Le Boutillier told jurors that she believed her daughter wanted to 'live her life' and that self-harm was 'never about dying' for Claire.
"She wanted to become a counsellor to help other people who had been through what she had," Ms Le Boutillier said. "Self-harm was the only way she felt able to calm herself down. She would only do it if she knew there was someone around who could help if she needed them."
Former Hospital manager, Sonya Cunningham, told jurors Ms Morris was the only patient being managed 24/7 at home at the facility, which was ran by Equilibrium Healthcare.
She told the court that when she returned to work from maternity leave in November 2021, Ms Morris voiced that she was unhappy with the way her care was being staffed.
"Claire was unhappy with not knowing who was turning up and it was increasing her anxiety," Ms Cunningham said.
"I wanted Claire to have notice of the rota as I agreed with her that it was distressing that she didn't know who to expect. We agreed to give her as much notice as we could. There was never a time where she didn't have sight of the rota before staff arrived.
"But there was such a high turnover of staff and I was increasingly relying on agencies. It would be 7pm at night and I was trying to find someone who was on her list of agreed staff."
The court heard that Ms Morris' care policy stated that "staff should always know the whereabouts of Claire," but that no prescribed time observations were written.
Ms Cunningham told jurors that despite this not being written down, she would have expected care staff to approach Ms Morris every 15 minutes to check her mood.
"I would expect it to be really clear in the care plan what the minimum times of approaching Claire would be and how it would be recorded," she said.
Jurors heard that a risk assessment of Ms Morris' likelihood of self-harming, which was carried out in August 2020, deemed the current risk as "medium" but historically 'very high.'
When asked by coroner, Zak Golombeck whether another review should have been completed in the run up to December, Ms Cunningham said "yes," adding "I don't know why one wasn't completed."
Commenting on the proposed Christmas rota provided to Ms Morris, Ms Cunningham said: "It was important for me to make sure everyone had a plan for Christmas.
"Claire wasn't happy that one of the team was going to be on nights over that period but that was a request from the member of staff due to personal issues not me," she said.
"Even though Claire felt there were significant concerns there wasn’t actually that many changes made to the rota. I am not undermining how she felt at all but I think she wanted things in a specific way that could not always be implemented."
The inquest continues.
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