The inquest revealed that Shannara Donnelly, known as Jade, was under high risk but was inadequately monitored, ultimately leading to her tragic death.
Barnet, Enfield and Haringey Mental Health NHS Trust’s director acknowledged failings in Jade's care, admitting that she should never have been sent to the hospital.
The report detailed serious lapses in care, including a lack of adequate risk assessment and insufficient observations, stating Jade 'should have been within eyesight observations'.
Jade's heartbreaking case highlights systemic failures within mental health services, emphasizing the need for stringent observation protocols for at-risk patients.
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