Failings have been identified in the care of a “funny, bubbly” young woman, who died after going missing from a mental health hospital.

Chelsea Louise Malthouse absconded from the Cherry Wood Ward at Littlebrook Hospital in Dartford in January last year.

Twelve hours later, she was found unconscious on a bench 40 miles away in Ashford town centre after taking a “designer drug”.

The 30-year-old was pronounced dead at the William Harvey Hospital shortly after, despite desperate CPR attempts to save her life.

On Tuesday afternoon, a jury of four women and seven men concluded her death was drug-related, but said shortfalls in her care may have contributed.

An inquest has been carried out over four days at Oakwood House in Maidstone.

Her family say they hope lessons are learnt after her death.

Coroner Katrina Hepburn heard how Chelsea was granted leave to smoke in the grounds of Littlebrook at about 10.10am on January 18, 2024, but did not return.

That evening she was seen on CCTV in Ashford town centre smoking with an unidentified man, who would later leave her unconscious on the bench.

The presence of a “designer drug” made to replicate cannabis in her blood has led to the belief that she could have become intoxicated while sharing a cigarette with the man.

She then lost consciousness and tragically choked on her own vomit, before being found at 11pm.

The jury, called upon to reach a verdict because Chelsea died under state detention, said: “The cigarette Chelsea is seen smoking, and the fact that she is seen convulsing before becoming unresponsive, are the only probable causes of death.

“We find that there were shortfalls in the support offered at Cherry Wood ward that possibly contributed to Chelsea's death.

“We find that there were inadequate drug outreach policies and education for Chelsea and staff members on the dangers of drug misuse.”

Chelsea was allowed to leave the hospital for 15 minutes, four times a day. This right, which requires doctors’ authorisation, comes under section 17 of the Mental Health Act.

The jury added: “More professional curiosity was needed when Chelsea refused urine drug testing, which may have given staff cause to revoke her section 17 leave.”

Chelsea’s aunt Sallyann Perkins, who raised her from birth, said she was “a beautiful ray of light inside and out, despite her mental health difficulties”.

“It’s been challenging for us to process our grief and accept that she is no longer here with us,” Ms Perkins said.

“Chelsea was loved by all who had the pleasure and privilege of knowing her.

“We will remember her as our daughter, sister, niece and friend.

“The inquest process has uncovered a lot of things about the care of those detained under the Mental Health Act.

“We have suffered an unimaginable loss, and we hope that lessons can be learnt by those responsible for caring for people like Chelsea to prevent this tragedy from happening again.”

Ms Perkins said her niece was “funny, bubbly, cheeky and could light up a room just by walking in”.

“She was the apple of my, and her brother John’s, eyes,” she added.

Last week, the jury heard evidence from police officers, who were called by members of the public who found Chelsea unconscious on the bench.

Detectives spoke to staff at The County Hotel Wetherspoon pub, who said she had been in at about 8.15pm, drank a pint and asked other customers to buy her alcohol.

She was later seen at Fountain Kebab, McDonald’s and the Global Mart corner shop.

Chelsea, who was originally from Ashford and worked as a cleaner, had withdrawn £100 in cash earlier in the day.

She was seen on CCTV at 9.58pm sitting on the bench with a man, where he uttered words thought to be “share it with me” and they began smoking a cigarette.

She sat next to him, and the footage then shows the man lying Chelsea down on the bench and leaving.

At 10.10pm, her body seems to convulse, before the man comes back, looks at her and walks away.

It would be almost an hour before a couple came across Chelsea and called for help.

Pathologist Benjamin Smith analysed her body and, on the balance of probabilities, said a mixture of drugs led her to lose consciousness.

Specialist testing revealed MBMB4 and ADB-BUTINACA - synthetic cannabinoids - were present in her blood.

Mr Smith said: “In conclusion, these tests have identified new novel drugs.

“This, on balance, could have caused a lack of consciousness and inhalation of vomit into the airways, which caused Chelsea's death.”

He added that there is no way of knowing how the new man-made substances may have interacted with the medication she was already on, due to a lack of scientific testing.

Toxicologist Dawn Reed gave insight into how synthetic cannabinoids can be consumed, saying: “World Health Organisation reports indicate the most common route is smoking or turning it into something that can be vaped.”

Medical staff at Littlebrook Hospital - run by the Kent and Medway NHS and Social Care Partnership Trust (KMPT) - also gave evidence, including psychiatrist Dr Oghenetejiri Obire.

He said Chelsea had been detained seven times under the Mental Health Act since 2015.

Her most recent admission was in March 2023, when she self-presented to the William Harvey and was then transferred to Littlebrook.

She stayed there and was deemed fit to be discharged by September 2023.

However, delays in sorting an appropriate “safe discharge plan” meant she was still on the Cherry Wood Ward in January 2024.

This was frustrating for the patient, who routinely expressed her desire to go and asked when she would be able to.

She used her section 17 leave to have a cigarette within the facility’s grounds. But on January 18, 2024, Chelsea did not return from her break.

When asked by Johnathon Metzer, a lawyer representing the family, why she was granted leave despite her history and high risk of absconding, Dr Obire said: “We felt she was clinically ready to go home but was waiting for accommodation.

“The ward is quite charged up. We tend to give patients who are ready to go home more time away from the ward. She was on her medication.

“When you balance that, we felt yes, she needed to be given leave because it is part of her fundamental human right.”

Dr Obire also told the inquest that staff were not allowed to accompany a patient during their section 17 leave if they were smoking.

A representative from adult social care at Kent County Council, Sylvia Mackenzie, spoke on Friday.

She explained the pathway for discharging patients. She said once someone is deemed fit to leave, a care plan must be put in place, and a panel must meet to agree to funding before looking for suitable accommodation.

In Chelsea’s case, she was waiting for the panel review. There were delays in this, partly due to the Christmas break.

Hospital bosses also wanted to contact police to make them aware of Chelsea’s situation before she was released. At the time, she was subject to an arrest warrant for missing a court date.

Following her death, most of Ashford town centre - between the junctions for Bank Street and Station Road - was cordoned off and remained so for much of the following day as officers carried out their investigation.

Floral tributes were left under a tree by the benches outside Sports Direct in the town centre in memory of Chelsea.

Her brother, John Malthouse, previously paid tribute in a GoFundMe page set up to pay for his sister’s funeral.

Chelsea’s family attended the inquest and wore colourful dragonfly broaches in her memory, as she loved the insects.

They told KentOnline they would like to thank Jake Fielding and Ellie Bullock of Southers Solicitors, Johnathon Metzer of One Crown Office Row, the coroner and the jury.7

A KMPT spokesperson said: “We are deeply sorry to the family and loved ones of Chelsea, who did not get all the help she needed when she was in our care.

“We have already made some important changes to improve our care.

“We have introduced a dedicated substance misuse pathway to ensure people receive the support they need.

“Additionally, our staff now have access to online education training on substance misuse.

“We have thoroughly reviewed how we assist our staff in assessing whether people can be allowed to safely leave our hospitals and follow the conditions set for doing so based on their current presentation and history.

“We are committed to delivering the highest standard of care.

“We will carefully and thoroughly examine the Coroner’s findings, which will help us identify ways to improve our services for everyone who uses them.

“Our unwavering commitment is to provide safe, effective, and compassionate care for every person who places their trust in us.”