A jury found there were 'inadequate security measures' at a mental health facility where a much loved mum was able to abscond before being hit and killed by a train.
Jacqueline Abrahams, 57, was an inpatient at Stansfield Place in Rochdale , where she was detained under the Mental Health Act after her mental health deteriorated following a number of 'life changes' that had sent her into the 'depths of despair'.
She died after being hit by a train at 8.08pm on February 24 last year, which left Smithy Bridge at 8.06pm and was due to arrive at Rochdale at 8.10pm.
Following an inquest this week at Rochdale Coroner's Court sitting in Heywood, a jury found that Mrs Abrahams, from Whitefield , Bury, went onto the railway lines 'with the intent of committing suicide'.
The jury also found that there were 'inadequate security measures in place in relation to the entry and exit from the building by the main entrance'.
There was also 'inaccurate record keeping of the observations undertaken', the jury found.
Mrs Abrahams had been subject to hourly observations by staff at the unit, which the jury also said they believed was the 'correct facility' for her needs.
She was last seen in the unit at 7.30pm, the inquest heard.
Staff raised the alarm during their 9pm checks when Mrs Abrahams was missing, but tragically she had already died.
Pennine Care NHS Foundation Trust, which runs Stansfield Place, said it will work with the coroner to address the issues raised by the jury.
During the inquest, the jury heard that Mrs Abrahams' mental health struggles began after the loss of both her parents and the breakdown of her marriage.
She had a background of self harm and 'risk-taking behaviour', including an overdose attempt at another mental health facility and two attempts to abscond from other wards.
Her daughter Bianca Abrahams once had to talk her mother down after she spent four hours on the wrong side of a motorway bridge on the M60.
In a statement released to the M.E.N. after the hearing on behalf of the family, daughters Bianca and Jourdana Davies, said: “After what has been a long and traumatic week for our family, today’s outcome has at least provided some solace on the basis that the jury’s findings echoed our concerns regarding the safeguarding of our mum whilst she was under the care of Stansfield Place.
“We hope that the implementation of facility improvements, additional security measures and the continued training of staff ensures that no more lives are put at risk.
“Having had to relive what has undoubtedly been the hardest two years full of pain, grief and anguish, we now simply wish to remember our mum as she was - very much in love with her life, family and friends, full of fun and adored.
“We would like to extend particular thanks to the coroner, Ms Judge, and the jury for handling this case with such sensitivity and to our legal representatives for their aid and support throughout”.
Henry Ticehurst, medical director of the trust, said: “Our thoughts and sympathies are with Jacqueline’s family and friends at this really difficult time.
"In light of today’s inquest findings we will work with the coroner to address the issues raised and continuously strive to provide the highest quality care to all our patients."
Joe Eley, a clinical negligence specialist at law firm Slater and Gordon, which is acting for the family, added: "Jacqui’s family had repeatedly expressed their very serious concerns about how vulnerable she was but were reassured that Stansfield Place was a secure unit where she would be safe.
"Instead, a high-risk patient with a history of absconding from hospital and self-harm was able to disappear without anyone alerting the police for at least 90 minutes.
"The harrowing evidence we have heard this week has answered some of the questions surrounding Jacqui’s death, but it is extremely concerning that the trust is still unable to offer a clear explanation as to how she was able to abscond in the first place. "Staff had also failed to keep accurate records of the observations carried out.
"While no one can be sure what Jacqui was thinking that day, had she been monitored more closely and had her care been what it should then tragically the outcome may have been very different."
