An architect who was killed by a high-speed train was failed by mental health services, an inquest heard.
The hearing into Joanna Bowring’s death at Boxley in June was told the 32-year-old had printed off Google maps and plotted the walking route to the Eurostar line from her parents’ house, 45 minutes away.
A camping chair, her shoes and a torch were found at the scene.
In the months before her death, Miss Bowring’s mental health rapidly deteriorated and she’d moved from her Chelsea flat to her parents’ Walderslade house after attempting to drown herself.
She heard voices telling her to kill herself and thought she was being followed.
When her parents went on holiday for two weeks at the start of April, Miss Bowring wouldn’t go as she thought The Royal Family were going to arrest her at the airport and send her to Guantanamo Bay.
That day her brother, Mark, took her to Medway Maritime Hospital as her health had worsened, she had packed a case and was determined to be admitted.
She was seen by two on-duty mental heath nurses who were told of her recent attempted suicide and the voices she was hearing.
"There has been significant learning from the death of Joanna. I have worked closely with her parents to identify problems and changes have been made. We are truly sorry for Joanna’s death" - Louise Clack
However, her situation was not deemed to be urgent enough to warrant admission to hospital, and home care through Kent and Medway NHS and Social Care Partnership Trust’s (KMPT) crisis team was arranged.
Mr Bowring told the hearing he was told by the nurses his sister did ideally require in-patient care but due to her being registered out of the area, this could not be arranged.
The trust denied this was said and stated the needs of the individual always trumped where they came from, although Louise Clack, KMPT’s acute services manager, did say due to government cuts clinical commissioning groups' are more aware of their boundaries and limited availability of beds.
Following the appointment the crisis team maintained regular contact with Miss Bowring, although her calls for her medication to be upped went unanswered for two weeks.
Her mother, Jean, said her daughter’s condition “nose-dived” in the final three weeks of her life and during a visit at the end of May, she told the team’s Dr Amrik Singh Joanna had ordered lengths of rope online and she was worried she would attempt suicide.
These concerns were not adequately dealt with and in-patient care was not given sufficient thought.
Miss Bowring died four days later.
Coroner Patricia Harding recorded a verdict of suicide.
Since Joanna Bowring’s death, KMPT has conducted an internal review into the care she received, identified issues and made changes to training and policies.
Louise Clack said risk assessment notes taken by Dr Amrik Singh after Miss Bowring’s last appointment were not sufficient.
She said Miss Bowring should have left the hospital with a care plan to set out her treatment.
She added: “Within the organisation we are concerned we are not involving carers as much as we should be. Since Joanna’s death we have started open dialogue training, have reiterated the importance of note taking and amended the system to allow for more subjective opinions to be recorded.
"To save other people’s lives, a better service is required" - Jean Bowring
“There has been significant learning from the death of Joanna. I have worked closely with her parents to identify problems and changes have been made. We are truly sorry for Joanna’s death.”
Mrs Harding made formal recommendations to KMPT that carers should be informed of "red flags" to look out for and should be included much more in the risk assessment stage.
She also said a care plan should always be provided to patients following an initial assessment.
Jean Bowring said: “To save other people’s lives, a better service is required.”
Speaking after the inquest, Miss Bowring's father, Norman, said: “The trust has admitted shortcomings in the care Joanna received and have started to put them right. In that sense we are very pleased something good may have come from her death.”
If you would like confidential support on an emotional issue, call Samaritans on 116 123 at any time.