Opportunities over the care of a mum were missed the day before she died in Bury, an inquest jury has said.
Jennifer Birkett, from Whiston in Merseyside, died aged 46 on May 7 last year at Fairfield General Hospital.
She had been a patient at Cygnet Hospital, off Buller Street in Bury, since 2015.
An inquest into her death at Rochdale Coroners' Court heard Jennifer stayed on the upper west ward as she was said to be a risk to herself and others but her children Luke and Lauren visited her weekly.
Lauren said that when they visited her mother for the last time, she looked fine and was in a positive mood.
Staff at Cygnet Hospital described Jennifer as funny and that she liked to sing and cared about staff.
Jennifer suffered from type 2 diabetes, schizoaffective disorder and emotionally unstable personality disorder. She had psychotic symptoms and heard voices telling her to harm herself.
She was said to have been physically and verbally abusive and her mood fluctuated, causing her to self-harm and act impulsively. She was detained and put in seclusion due to the outbursts.
In January 2022, there were concerns due to her high blood sugar readings and she was said to be at high risk of secreting medication and did this often.
She would also not follow the care management plans that she was put on for her diabetes, the inquest was told.
Then in February last year, Jennifer was placed in seclusion for four months before going back to the upper west ward.
It was said at this time she was doing well and was working towards being able to have leave off the ward.
But she would still self-harm in the form of overdoses, cutting and head banging after hearing voices in her head.
Safety plans were in place for Jennifer after concerns of her spitting out her medication. Room searches were made and she was watched for 15 minutes after taking medication.
On May 6, 2022, it was recorded that Jennifer vomited at around 9pm after an observation, which happened four times an hour.
More detailed physical observations were then undertaken at 10pm and 11.15pm.
At 5.30am the following morning on May 7, nurses noticed vomit in Jennifer’s room and that she had low blood pressure.
It was thought that Jennifer had been sick a few times throughout the night.
Another physical observation took place at that time and a discussion took place about whether a doctor should have been called the evening before.
There was only one nurse on the upper west ward on May 7 and at 12.10pm Jennifer requested some water and was restless.
But at 12.28pm Jennifer refused food and water and was pale and restless. An emergency call was made to other staff in the hospital and paramedics were called.
Jennifer was taken to A&E at Fairfield General but she died at 11.43pm that night with excessive levels of metformin found in her system.
After around five hours of deliberation, the inquest jury concluded that Jennifer's death was due to metformin toxicity, a drug for diabetes.
Speaking on behalf of the jury, one member said that there were "missed opportunities" to do checks on Jennifer before the medical emergency.
Senior coroner Joanne Kearsley said to the family: “It’s no secret she had been immensely unwell, I can imagine how difficult that must have been for many years.
“I want to offer my sympathies and my condolences to you all.”
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