DORSET Coroner Rachael Griffin has expressed “great concern” over the circumstances leading to the suicide of a mother-of-three at St Ann’s psychiatric hospital.

Thippawan Donnelly, aged 36, who was known as Thippy, died three days after staff discovered her unresponsive in a locked toilet at St Ann’s with a plastic hospital laundry bag tied over her head.

During a two-day inquest held at Bournemouth Coroner’s Court, evidence was heard how in the weeks leading up to her death Ms Donnelly, who was born in Bangkok, Thailand, and was known to mental healthcare workers in Dorset, had tried to kill herself several times.

On two of these occasions she had also tied a plastic bag around her head, the hearing was told.

Richard Vincent, father of Ms Donnelly’s youngest child, said: “She needed help but didn’t receive the help she really hoped for. I hope that nobody else will have to go though this at St Ann’s. There are three children that have been left without their mother.

“This could have partly been prevented by more control and proper supervision of plastic bags. It shouldn’t have happened.”

Yesterday, the hearing heard from Dr Julian Beezhold, a consultant psychiatrist commissioned by Dorset Healthcare University NHS Foundation Trust to carry out an independent review following the tragedy. His report made 50 recommendations and led to the trust implementing an action plan. This plan included the introduction of additional staff training; enhanced record keeping assessments; new protocols for patient transfer; and the removal of plastic laundry bags from wards. Recording a verdict of suicide, Ms Griffin said: “Ms Donnelly was a lady who has been described to me, during the course of this hearing, as unpredictable at times. She was a lady whose mood and stability was very much up and down.

“Between June 6, 2016, and July 14, 2016, there were a number of occasions where she harmed herself or undertook acts to end her life. There were times when it was thought Ms Donnelly did the act intending to end her life, and there were times when she did the act as a cry for help - wanting to show people how distressed she was.”

Ms Donnelly was admitted to St Ann’s Hospital as a voluntary inpatient on June 7, 2016.

Ms Griffin said: “On July 14, 2016, Ms Donnelly was found in a collapsed and unresponsive condition in a locked toilet on the Chine ward of St Ann’s Hospital, with a plastic laundry bag tied around her head.

“She was taken to Poole Hospital, where sadly her condition deteriorated, and she died on July 17.

“It does cause me great concern that she did have access to items that were not associated to her, such as her clothing, that sadly caused her death.

“Throughout this inquiry I have considered whether I am required in my duty to submit a report to Dorset Healthcare University Foundation Trust because of the concerns I have.

“It is not appropriate for me to do so in these circumstances, as Dorset Healthcare has taken significant action following Ms Donnelly’s death.”

“They’ve taken particular action in relation to access to items such as plastic laundry bags on the wards. Therefore, those concerns I do have, I’m satisfied they have been addressed.”