A CORONER has ordered an immediate investigation into the safety of a psychiatric ward she described as “total chaos” after a young woman was found hanging.

Bethany Tenquist had a history of mental health problems including bulimia, substance misuse and emotional unstable personality disorder.

The 26-year-old was being treated in psychiatric hospital Mill View, Hove, where she was found hanging last year.

She died 16 days later.

A pre-inquest review into her death heard Brighton and Hove coroner Veronica Hamilton-Deeley order a regulation 28 report, an investigation to prevent future fatalities, into the presence of ligatures in the ward.

She said two had been found in Ms Tenquist’s room during checks.

But one was left behind which the young woman used to kill herself.

The inquest heard staff did not call the police when Ms Tenquist was found hanging on December 29 last year.

Ms Hamilton-Deeley asked Ryan Carter, the paralegal representing Sussex Partnership Trust at the inquest held in Brighton, to investigate the protocol for involving police in incidents such as Ms Tenquist’s.

She said: “On March 7 this year police were called to a different woman in hospital who had tied ligatures around her neck.

“Why were police not called for Ms Tenquist? Information is power.”

A paramedic tending to Ms Tenquist the night she was found said in a statement that staff reported the young patient was seen “staggering” down the corridor, clearly intoxicated, earlier that night.

Dr Hazel Dent had been to check on Ms Tenquist after concern about her welfare and requested nurses continue 15-minute observations.

But the court heard a nurse only called for a response from Ms Tenquist rather than checking on her physically.

Ms Hamilton-Deeley said: “That is certainly not the way observations should be carried out.

“Patients could just reply while tying something around their neck.

“There should be active engagement with the patient during observations.”

She ordered Mr Carter to investigate levels of staff in the ward.

She said: “It seems Caburn ward is very volatile.

“The Argus published a story about another patient, Lauren Shipton, who was with Ms Tenquist, who said they had access to razors and alcohol. It seems total chaos.”

Ms Hamilton-Deeley said action has been taken by the trust to look into the presence of alcohol on the ward. She said: “The other thing that is worrying is the access to sharps, particularly razors, which I would like to be taken seriously by the trust.”

She said Detective Sergeant James Meanwell, in charge of the police investigation into Ms Tenquist’s death, is “being given the run around” by staff at Mill View.

She has adjourned the inquest until he is given the information he needs.

She said: “I am going to write a letter to the CEO of Mill View explaining my anxieties and that I want the police to be co-operated with. We will see if there are mistakes to learn.”

Mr Carter told the court: “As the trust, we will take this very very seriously. We will include in our serious incident report the points that have been raised.”

Ms Hamilton-Deeley said: “It’s difficult to know why someone killed themselves and it can be very hard to prevent it, even in managed situations. But when someone manages to do it in circumstances that are mismanaged and chaotic, this needs to be looked at.”

A date will be decided when DS Meanwell has obtained the information needed for the inquest.