Mum's promise to help end mental health deaths
A heartbroken mother said she would do "everything I can" to make sure the circumstances that led to her daughter's death were not repeated.
Elise Sebastian was 16 when she was found unresponsive in her room at the St Aubyn Centre mental health unit in Colchester in April 2021.
An inquest jury at Essex Coroner's Court concluded that "poorly administered observations" contributed to her death.
Victoria Sebastian said she would be taking part in the ongoing Lampard Inquiry, which is investigating the deaths of more than 2,000 mental health patients in Essex.
"I will be fighting with the inquiry and doing everything I possibly can to make sure, no matter how painful it is for me and my family, nobody else has to do this because it is heartbreaking," she said.
The Essex Partnership University NHS Foundation Trust (EPUT) runs the unit, and chief executive Paul Scott apologised to Elise's family.
Elise, a big Harry Potter and music lover, lived in Southminster near Maldon.
She had been diagnosed with autism and her parents became increasingly concerned about her anxiety and depression, and in March 2021, she was admitted to the unit for a second time.
The inquest heard she was supposed to be receiving one-to-one care, but on 17 April, she was left in her room for 28 minutes.
Jurors were told how staff muted an audible alert that was part of a new infrared monitoring system, that had been installed in the unit two months previous.
EPUT accepted the trust's failures were "causative of her death" and its lawyer Pravin Fernando said: "[It] failed in its responsibility by allowing her to enter her bedroom unsupervised."
Speaking after the conclusion, Mrs Sebastian said her daughter was "dramatically and horrendously" failed and that she was treated as an "inconvenience" in the unit.
"She was meant to be safe, but instead she was allowed to make several attempts to take her own life in the days leading up to her passing, until she finally succeeded," she continued.
"There have been too many deaths.
"It is the most painful thing ever to lose a child and I will do everything I can to make sure it doesn't happen to somebody else's child.
"Lessons should have been learnt and I should still have had my beautiful baby girl."
The Lampard Inquiry team has been monitoring the progress of the inquest.
Mr Scott said: "I want to say sorry to Elise's family and to everyone who loved her that she did not receive the care she deserved, and I offer my deepest condolences."
If you have been affected by this story or would like support then you can find organisations which offer help and information at the BBC Action Line.
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Neglect at unit led to teenager's death - inquest
Alert muted before teen died at unit, inquest told
NHS trust admits failures led to teenager's death
Essex Partnership University NHS Foundation Trust
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