THE family of a Southampton woman say they feel changes made by a health trust 'don't address the care deficiency' following an inquest into her death.

It comes after a senior coroner criticised the treatment of Eleanor Brabant, a patient at Southern Health NHS Foundation Trust's Antelope House facility in Southampton who was found hanging in her room on November 2 last year.

Ms Brabant died three days later at Southampton General Hospital.

Winchester Coroner's Court heard opportunities to improve Ms Brabant's care were missed, someone had gone into Ms Brabant's room after she had been rushed to hospital, but before police had attended, and a "critical piece of information" was not given to officers.

Southern Health's medical director Dr Karl Marlowe attended court to apologise directly to her family.

Dr Marlowe said: "Our staff work with the most vulnerable in society. I'm deeply sorry we were unable to keep Eleanor safe in our care."

He later added in a statement: "This is a devastating time for Ellie’s family and I express to them my deepest condolences and those of all our staff. Whilst I cannot begin to imagine what Ellie’s family are experiencing, I sincerely hope this week’s inquest has provided more clarity and answers that will, in some small way, be helpful.

“Since Ellie’s death, care at the hospital has been comprehensively reviewed, changes have been made and ongoing improvements are taking place.

“Whilst it is sadly not possible for any healthcare provider to completely eliminate all risks and challenges undoubtedly remain, improvements are being made and we continue to work alongside our staff, patients and their families to make the hospital the safest it can possibly be.”

The inquest heard that Ms Brabant had been detained under the Mental Health Act after years of mental health problems and drug misuse, but the decision was taken to release her in September 2017, meaning the 28-year-old, Winn Road, Portswood, would be a voluntary patient.

Senior Hampshire coroner Grahame Short criticised removing the legal detention, saying: "I find that this was a premature decision." Mr Short added an "adequate" care plan was not in place and this contributed to her death.

Recording a conclusion of 'suicide while the balance of her mind was disturbed', Mr Short added: "I accept Ellie (Ms Brabant) frequently changed her mind. Ellie was described as impulsive.

"It was a far from easy task (treating Ms Brabant) and I accept this case showed there was a range of clinical opinions.

"Ellie, I believe, need the security of well defined boundaries in her life."

Mr Short also said he would be sending a 'prevention of future deaths' report to Southern Health recommending changes at the trust, and would be making police aware about the existence of documents not previously given to them.

Following the inquest, Ms Brabant's family released a statement, saying: “We are devastated by Ellie’s death and the failures in her care at Antelope House. We were not given the opportunity to feed into Ellie’s care and were instead left to watch her rapid decline. The Ellie who took her own life was not the Ellie we knew.

"Although we accept procedural changes have been made following Ellie’s death, we do not believe these changes address the fundamental deficiency in Ellie’s care. We do not feel confident that should another patient like Ellie be under Southern Health’s care, anything would be done differently.”

Alice Stevens, the family's solicitor, of Broudie Jackson Canter Solicitors, added: “I also have concerns about the way the inquest process was handled by Southern Health given that they admitted Ellie’s room had been cleaned prior the police arriving to complete their investigation and that key evidence was only provided on the final day of the inquest.

"I am glad that the coroner has taken these matters seriously and hope that his letter to the trust and prevention of future dearth report is given serious consideration by the trust.”