An inquest into the death of a young woman who was admitted to a psychiatric unit as a suicide risk, has found that the hospital’s neglect and lack of continuous observation contributed to her death. Becky Jones was taken to the Lister psychiatric unit in Stevenage, Hertfordshire as a place of safety under s. 136 of the Mental Health Act 1986 after being observed wandering on train tracks nearby. Becky was deemed by the nurse in charge as a low risk although she had been treated at the unit since 2007 and had a history of trying to kill herself. The nurse in charge had worked a double shift that day which the jury found impaired her ability to carry out her responsibilities as s. 136 bleepholder that night. The nurse did not continuously observe Becky and she subsequently went missing from the unit for several hours. It is thought that Becky gained access to a hospital roof and was found dead on the roof of the mortuary below. The jury recorded an open verdict as it could not be sure that she had committed suicide. The hospital has admitted liability in negligence and damages have been paid to her family. The Hertfordshire Partnership University NHS Foundation which runs the unit expressed their sincere condolences and launched an investigation resulting in a number of actions to be implemented to reduce the risk of such an event happening again. Kirsten Sjovoll was instructed by Nancy Collins at Irwin Mitchell.