A MOTHER-of-two jumped to her death after a three-week wait for a hospital bed to treat her severe depression – but her case "slipped through the net", an inquest heard yesterday.
Melissa Heselden, 30, died from multiple injuries after jumping over railings on Scammonden Bridge, which crosses the M62 in West Yorkshire, and falling onto the embankment below.
But the inquest in Huddersfield was told a psychiatrist and her doctor had called for her to be admitted to the Roundhay Wing at St James's Hospital in Leeds more than three weeks earlier after her long-standing depressive illness worsened.
But a bed could not be found immediately and the hearing was told that despite appeals to the unit from her family and her GP she was never admitted.
West Yorkshire coroner Roger Whittaker said her death was "tragic".
He would write urgently to NHS chiefs to tell them there appeared to be no procedures in place to ensure patients were called to hospital once a bed was available.
Miss Heselden had been discharged from the Roundhay Wing in August after a short stay during which her condition improved.
But on October 5, 2001, her GP and a locum consultant psychiatrist called to her home in East End Park, Leeds, found she had again deteriorated.
She agreed to return to the Roundhay Wing where it was hoped a bed would become available later that day.
Paul Assame, who was then the bed co-ordinator for the unit, said it remained full over the weekend but he would have expected a bed to have become free within a week.
He could not explain why she had not been admitted, but concluded "there must have been some communication breakdown".
At the time, he said there was no system in place to check an admission had taken place.
Locum psychiatrist Akideli Atere said he had been concerned she could harm herself and he would have expected hospital staff to contact him if no bed could be found.
His spell at the hospital ended four days after the home consultation but he said there was no handover to the doctor who replaced him.
Miss Heselden's GP of 20 years, David Dowson, said he found her very withdrawn on a home visit on October 15 although he did not consider her an immediate suicide risk.
He was surprised no bed had been found for her.
He rang the Roundhay Wing and was given the impression she would be admitted "within a week".
"I felt fairly confident the hospital had everything in hand," he said.
Solicitor Fiona Borrill, for Miss Heselden's family, urged the coroner to consider that there had been a "systems failure" at the hospital which had amounted to a "lack of care".
Mr Whittaker said it was "inconceivable" that no bed had become free over the three weeks before her death on October 29.
"But for some reason the notification of that bed was not relayed to the family.
"She slipped through the net," he said.
"There appears to me no system in place which would ensure continuity of arrangements for notifying patients of bed availability and calling patients in."
But he said he could not be certain that if she had been given a bed there would have been a different outcome and recorded a verdict that she had killed herself.
"Although there are problems disclosed here within the hospital, regrettable as they may be, I don't believe this is a case where you can say that if this or that was done it will prevent similar fatalities."
In a statement afterwards on behalf of the family, Miss Borrill said they remained distressed and concerned about what had happened.
"They feel more could have been done to get her into hospital to receive treatment."
They also wanted to know what the hospital had done to make sure other patients did not "disappear from the system".
Last night Leeds Mental Health Teaching NHS Trust refused to reveal what changes it had made.
A spokesman confirmed a review of the case had been carried out and an action plan had been agreed but it would await the coroner's letter.