A coroner has blasted mental health professionals for failing a teenage girl who was found hanged after suffering delusions about being a super hero.
Victoria Halliday, 19, believed she was on a mission to rescue the ‘good people’ from the top of the 140ft tall Xscape building when police rescued her.
An inquest heard voices in her head told her she had to complete her mission or commit suicide.
The teen, who had already been warned by police after climbing the outside of a building in Leicester, was saved from the Xscape building by police.
But just two weeks later, on July 30 last year, she was found hanged in woodland in Leicestershire after going missing 10 times.
An inquest held at Leicester Town Hall heard Victoria went missing three times - to Milton Keynes and Cardiff - between April and July 15 prompting police searches.
She was seen four times by staff at the mental health unit in Milton Keynes hospital after police were concerned for her safety.
The four day hearing at heard Victoria, from Broughton Astley, Leicestershire, had told mental health staff she heard voices telling her to complete a mission.
She said she had superpowers and could climb anything.
Doctors at the Bradgate Unit in Leicester discounted suggestions that she was suffering from psychosis saying the delusions were part of her personality disorder.
Coroner Lydia Brown said she had a number of serious concerns about how the Leicestershire Partnership NHS Trust treated Victoria in the months before her death.
She also criticised the quality of the community mental care services in Leicestershire and the refusal of the trust to act on the views of her family doctor and her personal counsellor.
Coroner Brown said if the NHS Trust had examined Victoria’s journals deeply, they would have seen signs of psychosis.
Independent psychiatrists said in patient care should have been considered - despite there being no psychiatric intensive care beds for women in Leicestershire.
Coroner Brown dismissed both a suicide or misadventure conclusion because she could not be certain that Victoria realised what she was doing.
Recording a narrative conclusion, she said: “Vicky’s mental health started to deteriorate in the early part of 2015 following a year of stability.
“She was sectioned under the Mental Health Act and admitted for impatient care in the Bradgate Unit, Leicester for diagnosis and treatment.
“She was diagnosed with emotionally unstable personality disorder, the plan was to care for Vicky in the community with expected ongoing brief admissions in times of crisis.
“During June and July 2015, Vicki repeatedly presented in crisis and numerous missing person reports required police involvement across various locations and she was brought back for psychiatric assessment due to concerns for her and the public’s safety.
“On each occasion she was discharged back into the community.
“Ample evidence was available to suggest that Vicky was starting to experience psychotic symptoms from May onwards but opportunities were missed to fully and adequately explore these and reconsider the necessity for in-patient care.”
She praised the dedication and professionalism of the Leicestershire police missing persons team in their repeated work in trying to safeguard Victoria.
She said Victoria “fell through the cracks in the system” and the family were left to “pay the ultimate price for the lack of appropriate care.”
Father Nigel Halliday said his family has paid the ultimate price because of the lack of appropriate care provided by the Leicestershire Partnership NHS Trust for his teenage daughter.
In a statement on behalf of the family, he said: “As a family we feel that Vicky was very badly let down and failed by the Mental Health Service, which was meant to protect her.
“We have paid the ultimate price for the hospital’s lack of appropriate care.”
He thanked the coroner for conducting a full and thorough inquiry into the tragic death of his daughter.
Mr Halliday said he was devastated to learn that there were a number of missed opportunities which affected the quality of care that was provided to his daughter.
Satheesh Kumar, medical director for Leicestershire Partnership NHS Trust (LPT), said: “First and foremost we want to extend our deepest sympathy once again to Victoria’s family for their loss.
“The wellbeing and safety of people in our care is paramount and we carried out an investigation around the circumstances of Victoria’s death to see what we could learn and improve to reduce the likelihood of further tragedies.
“We take the coroner’s comments very seriously and will not leave any stone unturned in addressing gaps or weakness in the system.
“We are committed to working with families in improving our ability to respond to and support families of people with complex needs like Victoria.”