Less than two months after Molly died, another patient at the unit was found dead in her room.
Cherie Boulton was on a different, low secure ward, called Ruby Frost, and was hoping to be discharged soon.
Her family said the 41-year-old had spent about 20 years in various mental health units but was due to move into an assisted living flat within six weeks. She had paranoid schizophrenia among other mental health conditions.
“I think she was excited because she’d been in these places for such a long time, but she was nervous,” her sister Gemma Boulton said.
Cherie was on hourly checks, the inquest into her death heard in July 2023.
Overnight, in the hours before she was found dead, all but one of the expected observations happened, but CCTV suggested staff only spent seconds observing whether she was safe and breathing, checking through a small window in her bedroom door.
As was the case with Molly, an observation was recorded, but it did not actually happen.
In documents seen by the BBC, staff said they were unable to see whether or not Cherie was breathing when they carried out their checks.
“Surely when you’re checking on someone, you’ve got to go in to check they’re OK,” Cherie’s mum Lynn said.
Cherie was found at 08:40 in the morning. The inquest was told rigor mortis – the stiffening of the body after death – had set in.
Although this generally happens hours after someone dies, the coroner in her inquest said it could not be used to provide an accurate time of death.
Her family says other patients at the unit have told them that Cherie had felt unwell the night before, but there is no record of this.
The inquest found Cherie died from pneumonia. The coroner found no evidence that failures in treatment contributed to her death.
Police investigated both Molly’s and Cherie’s deaths. No-one has been charged.
“She’s been gone for three years now, and it still hurts and it’s still painful and it always will be,” Lynn said.