FAILURE to contact a young woman who had made it clear that she intended to take her own life was “a significant omission in her care and treatment”, a coroner has said.

At an inquest in Ruthin Hannah Browning’s care co-ordinator and manager of the Ty Derbyn mental health unit at Wrexham Maelor Hospital, accepted they should have acted differently in response to the 22-year-old clear intention.

Shortly after walking out of a meeting with them Hannah was found hanging in Marford Quarry, close to her home. She never recovered consciousness and died two days later on October 12, 2018.

At the end of a four-day hearing John Gittins, coroner for North Wales East and Central, said: “This was a young woman in crisis for whom more should have been done.

“Notwithstanding that fact, I also find that there is no evidence by which this lapse could be considered to have led directly to her death.”

The inquest heard that Hannah, a student at Nottingham University, had been under the care of the mental health team for several months after repeatedly self-harming and threatening to kill herself.

Her mental health problems stemmed from her having been raped at the age of 13 at the same spot - a fact she kept to herself until she went to university.

The inquest heard that the investigation into the rape formed part of Operation Lenten which focussed on sexual assaults carried out by members of the travelling community.

The alleged rapist was interviewed but not charged, but the coroner said that North Wales Police officers and a representative of Barnardos, who was asked by the police to offer Hannah support, treated her with sensitivity and compassion.

She was diagnosed with Emotionally Unstable Personality Disorder (EUPD), and the coroner found that her treatment as both an in and out-patient was appropriate.

He found, however, that there was a “lack of a cohesive communication strategy with outside agencies such as Barnardo’s, North Wales Police, who investigated the rape allegation, and the provider of Dialectical Behaviour Therapy (DBT), which Hannah’s family paid for privately.

Consultant psychiatrist Dr John Clifford, explaining the treatment processes applied in her case over the months leading to her death, described her as “an exceptional person who had achieved a huge amount over 21 years”.

But he added: “She also had a huge burden on her shoulders”.

The coroner recorded a narrative conclusion in which he said her illness was probably triggered by the rape and exacerbated by her chronic back pain.

“On the 10th of October, 2018, she expressed to persons engaged in her care and treatment that it was her intention to end her life that day, yet despite this inadequate arrangements were made to protect her and insufficient efforts were made to keep her safe,” he said.

He issued a Regulation 28 notice for the prevention of future deaths to both the Betsi Cadwaladr University Health Board and Wrexham County Borough Council, who shared responsibility for her care, as he said he had received no reassurance that every effort would be made in future to contact a person who had made a credible threat to take their own life.

Speaking after the inquest, Iain Wilkie, Interim Director of Mental Health and Learning Disabilities at Betsi Cadwaladr University Health Board, said: “I wish to extend our sincere condolences to Hannah’s family at this very difficult time.

“We accept the Coroner’s findings and we will work with our local authority partners to improve our processes, so we can reduce the likelihood of a tragic event like this from occurring in the future.”

Alwyn Jones, Chief Officer Social Care, added: “We have fully cooperated with the Coroner’s Inquest and will now respond to the Regulation 28. We will also take the opportunity to review our processes to see how any further deaths could be avoided. We extend our sincere condolences to the family.”

Anyone having thoughts of self-harm can call the Samaritans' 24-hour helpline on 116 123.