A 'beautiful, caring' aspiring veterinary nurse who 'just gave up' following several attempts to take her own life was let down by medics, an inquest heard.
Lauren Finch, 23, was found hanged in her room at Atherleigh Park Hospital in Leigh, where she was a patient, on September 17 last year.
She died from her injuries in hospital a week later.
A jury at Bolton Coroners' Court recorded a conclusion of suicide after finding that the care provided by professionals was found to be a contributing factor in her death.
As a result, coroner Rachel Galloway will write a report to the North West Boroughs Healthcare NHS Foundation Trust with recommendations for improvements, in the hope future deaths can be prevented.
Specifically, the jury found that the risk of Lauren taking her own life was not properly assessed and observation levels were not correct.
During the 10-day inquest, the jury heard Lauren, from Wigan, tried to take her own life on several occasions in the months leading up to her death - and had escaped from Atherleigh Park on several occasions.
Her mother Victoria criticised the response of staff at the facility. She accused them of failing to listen to her concerns and being 'dismissive' of her daughter's feelings.
She said she could not understand why her daughter kept being discharged without any care arrangements in place, despite repeated suicide attempts.
Mrs Finch said it was like a 'rollercoaster' for her and Lauren, and that she felt like her daughter was 'just another number'.
"She gave up in the end, she had just lost faith", Mrs Finch said.
Lauren had a history of mental illness and had been diagnosed with depression, anxiety and ‘emotionally unstable personality disorder’.
In early 2018, she spent several periods on the Westleigh Ward at Atherleigh Park Hospital, the inquest heard.
She was discharged a week after her first admission - a decision her mother was unhappy about as she felt it was 'not enough time to make a difference'.
Throughout the summer, Lauren was admitted to the hospital several times following repeated attempts to take her own life.
On April 28, police were called after a member of public saw her threatening to jump into a river in Wigan.
In June, police had to pull her back from the edge of a multi-storey car park in the town centre.
Less than two weeks later, Lauren was found on a bridge after self-harming and taking a large quantity of tablets.
She was repeatedly sectioned before being discharged from the hospital - which Mrs Finch said made her feel like her daughter was being 'pushed from person to person, service to service, without the treatment she needed'.
Lauren had 'lost trust in the service', her mum said.
In the days leading up to her death, Lauren had been at a 'low ebb'.
She went missing on September 13 and was found by police with cuts to her arm.
She had told her family that she was heading out to take their dog for a walk, but instead left the animal tied up in the garden.
Lauren was sectioned once more and readmitted to Atherleigh Park, but the following day, she ran off from the facility while waiting for a taxi after being discharged.
She was found on the East Lancs Road and told police she had been making her way to the M6 to end her life.
On September 16, Lauren managed to abscond from the hospital again after following a doctor through a door.
Police officers traced her to Lilford Park and managed to restrain her following a short chase.
Mrs Finch said the incident left her daughter 'petrified' and with bruising to her ribs and the side of her body.
She claimed one officer had knelt on Lauren's ribs and put his fingers on a pressure point behind her ears, before calling her a 'stupid girl' and asking why she had tried to run off.
In his evidence, the police officer confirmed that the pressure point technique was used because Lauren was 'thrashing around on the floor' and saying she 'wanted to die'.
But he said he 'did not recall' calling her a 'stupid girl'.
The jury said that when Lauren absconded from the facility and there was 'police involvement', that this would have had an 'impact on her state of mind'.
The following day, Mrs Finch contacted the manager of the ward Lauren was staying on to say she was unhappy about her care and the fact she had been allowed to escape.
She believed more should have been to ensure her safety and stop her escaping.
Later that day, Mrs Finch received the devastating phone call from staff to say her daughter had been taken to Royal Bolton Hospital after being found collapsed in her room.
The inquest heard how in the hours before her death, ward staff had decided to change the frequency of observations on Lauren from every 10 minutes to every 30 minutes, during a staff handover.
The trust has since amended its observation policy and said all staff will be provided face-to-face training on the revised policy.
After the inquest, John Heritage, chief operating officer at North West Boroughs Healthcare NHS Foundation Trust, said: “I would like to offer my sincere condolences to Lauren’s family. I appreciate it must be incredibly difficult to sit through a long inquest on top of losing someone you love.
“We know we made mistakes during Lauren’s care and have openly admitted these failings as part of the inquest process. We wholeheartedly apologise to Lauren’s family for these shortcomings and the understandable distress this has caused.
“A comprehensive investigation took place immediately after Lauren’s death and changes have been made to help minimise the risk of any similar incidents occurring in the future.
“We have strengthened our Observation, Safety and Engagement Procedure and over the coming months we are introducing an electronic system which will enable staff to use iPads to update records in real time as observations are carried out."
Paying tribute to her daughter, Mrs Finch described her as 'an intelligent, beautiful, caring and kind girl'.
She added: "Lauren was a gentle soul and the pain of missing her is unbearable.
"She is missed every day."
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