A MENTAL health patient jumped to her death from the Brunel West multi-storey car park in Swindon’s town centre after walking out of specialist respite centre, an inquest heard.

Debbie Costello, 41, of Park North, who suffered from a personality disorder, committed suicide after leaving Oak Lodge in Stratton St Margaret.

Avon and Wiltshire Mental Health Partnership NHS Trust (AWP), a major provider of mental health care services in Swindon, was not blamed for the death but is reviewing its procedures as a result.

The inquest at Swindon’s Civic Offices heard that Mrs Costello’s state of mind could change quickly, meaning she would be happy one moment and depressed or suicidal the next.

Her husband, Peter, said she had a history of overdosing on medication to cope with the illness and had been twice sectioned in the past after attempting to jump from car parks.

He said his wife, who was visited regularly by a community psychiatric nurse, was particularly unwell in 2008 following an operation.

She was admitted to the Great Western Hospital three times during January 2009 after overdosing on medication.

Mrs Costello was referred by AWP to stay for two weeks at Oak Lodge, a respite centre run by the charity Swindon Mind.

The inquest heard that an initial assessment on January 30 warned that Mrs Costello had suicidal intentions but a further assessment on February 4 did not identify such risks.

Staff at Oak Lodge said Mrs Costello was happy and relaxed during her first few days but started showing signs of stress and depression on February 13.

She complained she could hear screaming in her head which was growing increasingly intrusive and she had to be given additional medication.

The crisis came to a head at about 11.15am on February 15 – only minutes after she had been visited by a mental health practitioner from the trust’s crisis team, the inquest heard.

In statements read at the inquest, guests said that Mrs Costello initially seemed fine, but she later left the centre after announcing she was going to jump off a bridge.

They went to look for her before deciding at about 1.45pm to alert staff at the crisis team, who called police.

Mrs Costello had travelled into the town centre and jumped from the top floor of the car park, causing fatal spinal injuries.

Coroner David Ridley said: “My conclusion is that Debbie Costello took her own life whilst suffering from a personality disorder with depressive features.

“She was suffering from a mental illness and I think that had a bearing on her actions.”

SWINDON Mind, the charity which runs Oak Lodge, has defended the procedure it had in place to deal with patient emergencies.

Stephanie Holt, manager of the respite centre, told the inquest that the lodge was in same premises as Sandalwood Court, where Avon and Wiltshire Mental Health Partnership’s crisis team is based.

She said: “We felt that everything was as it should be. We always say to guests that if you are worried about anything, you have access to the crisis team.

“The crisis team is in the same building as us. You can go around and knock on the door or you can ring and phone them.

“I don’t know what else we can modify to make it safer.”

HEALTH chiefs at the NHS trust responsible for providing mental health services in Swindon are reviewing their procedures following Mrs Costello’s death.

The Avon and Wiltshire Mental Health Partnership NHS Trust (AWP) commissioned an unexplained death audit which has led to four key recommendations for improvements.

The inquest was told that although the audit was initiated as a direct result of the death, the suggested improvements did not relate specifically to the case and might not have prevented Mrs Costello’s death.

Richard Kerley, manager of the crisis team at Sandalwood Court in Stratton, said procedures had already been changed in April so medication for guests at Oak Lodge are prescribed by AWP staff instead of GPs.

He said one recommendation in the report was that guests should be visited by staff from the same AWP department which had referred them to the centre to ensure continuity of care.

Mr Kerley said another suggestion was that communication should be improved between staff at AWP and Swindon Mind, which runs the centre.

He said the final recommendation was that risk assessments of patients should be ‘dynamic’ to ensure the service can quickly identify problems.

Speaking after the inquest, a spokesman for AWP added: “As the inquest heard, the coroner made no criticism of the mental health care provided to Mrs Costello.

“We (Avon and Wiltshire Mental Health Partnership NHS Trust) always carry out our own internal investigation to see if any lessons can be learned.

“We would like to offer our sincere condolences to Mrs Costello’s family.”