A Leeds teenager took her own life after being transferred to a mental health hospital 170 miles away from home.
Mia Titheridge, 17, from Alwoodley, was found unresponsive in her room at Huntercombe Hospital, near Norwich, in the early hours of March 19 2017.
Mia, described as a "beautiful" young woman by her family, was moved to the Norwich hospital from a hospital in Sheffield after repeated attempts of self-harm.
She was considered a high-risk patient and was supposed to be on 15 minute observations.
However, she was not checked on for almost an hour before she was found.
The teenager was taken to Norfolk and Norwich Hospital where she died a few hours later.
An inquest into her death concluded that Mia died as a result of suicide after failures by the hospital to respond to Mia’s threats to take her life and failures to carry out frequent observations on the night she was found fatally injured.
Norfolk Coroner’s Court also heard that Mia brought a ligature and alcohol back to the hospital following a home visit the weekend before her death.
Staff did not find this in their searches.
Mia's mum Tori said her daughter was her "world" and said the family have been left feeling that her death "could have been prevented."
Mrs Titheridge said: "We were against Mia being moved because of the distance. She was going to be moved to a place where she would be isolated and alone, hundreds of miles from her family and friends who could offer her the support she needed.
“Mia was terrified when she was transferred. We just didn’t see how this would help with her rehabilitation.
“The last time I saw Mia she thanked me for a lovely weekend. Little did I know that would be the last time I saw my beautiful daughter.
The 44-year-old added: “Mia was my world. She was the most beautiful daughter I could have wished for who had her entire future ahead of her. We remain absolutely devastated that she is longer here and will not get to fulfil her ambitions or celebrate milestones in life such as starting work or getting married.
“Listening to the evidence around why she died has been heart-breaking but what is even worse is that we are left with the feeling that Mia’s death could have been prevented.
“It is difficult not to think that those who were supposed to provide the care she needed to make her better let her down when she needed help the most."
The Care Quality Commission inspected Huntercombe Hospital on 13 and 14 March, 2017 - days before Mia’s death – and again on 23 March, 2017.
It rated the hospital as requiring improvement.
It was closed following an unannounced CQC inspection report in February 2018.
The government inspector ordered no new young patients be admitted due to “significant and immediate concerns that required immediate action.”
Since Mia's death, her family has called for improvements to be made in the care young people with a mental health Illness receive.
Mrs Titheridge said: "Sending vulnerable people, particularly young people, hundreds of miles away from home to receive treatment does not work. We feel that more needs to be done to ensure their loved ones who can provide vital encouragement and support remain close by.
"While we know that nothing can ever bring Mia back we will continue to campaign for improvements in mental health provision as we would not wish the hurt and pain we are left to face every day on anyone else."
Tania Harrison, expert medical negligence lawyer at Irwin Mitchell representing Mia’s family said after the inquest: “This is an incredibly tragic case and sadly one of a growing number we are seeing where vulnerable young people with mental health difficulties have not received the care they deserve.
“For more than two years Tori and the rest of the family have held a number of concerns about the events that unfolded in the lead up to Mia’s death.
“While we are pleased that we have been able to provide Mia’s family with the answers they deserve, nothing will make up for the anguish and pain her family continue to face.
“Some of the evidence into the care Mia received heard during the inquest is extremely worrying. While this hospital may have closed it is now vital that all mental health providers take note of this inquest and where appropriate learn lessons from Mia’s death to improve patient care.
“We will continue to support Tori and the rest of the family at this incredibly difficult time to help them try and come to terms with what happened as best they can.”
A spokeswoman for The Huntercombe Group said: “First and foremost, we express our deepest condolences to the family and friends of Mia Titheridge.
“The purpose of an inquest is to enable a coroner to understand the circumstances around a patient's death.
“This inquest highlighted that one registered mental health nurse failed in their professional duty of care and did not carry out the observations of Mia they were required to do.
"As a result of this nurse’s actions we (along with the Coroner) referred them again to the Nursing and Midwifery Council to consider action against this individual.
“We also supported the letter the Coroner issued to the Royal College of Psychiatrists and the issue of referral to the General Medical Council with regards to the actions of two individual clinicians.
“We will also be proactively conducting spot checks on CCTV on nightshifts to ensure staff observation duties are met.
“Our highest priority will always be the health, safety and wellbeing of the people in our care.”