The family’s lawyers, Stewarts Law, said the coroner recorded a narrative conclusion and found that a plan for Chanel to be observed on a one-to-one basis by a mental health nurse was not carried out.
They said the coroner concluded that if it had been, it was “possible, not probable” that it could have made a material difference to the outcome.
The firm said Chanel was twice found slumped in her chair, but no contemporaneous notes were made, making the timeline unclear.
They added that there were seven mental health patients in A&E overnight and only two mental health nurses on duty, both already allocated.
Muriel said: “What has been established is that she was put on a plan to have one-to-one supervision. This plan was never executed or actioned.
“It is really clear now because we have gone through an investigation with Barnet, then we’ve obviously gone through the coroner’s inquest and the outcome is she did not have one-to-one supervision and the registered mental health nurse that should have been with her.”
She said one issue identified was the hospital’s reliance on agency healthcare staff.
While the hospital attempted to get additional staff in, none were available.
“And lo and behold, she has a cardiac arrest,” Muriel said
“She may have been left for up to half an hour until someone noticed her. So how does she go unnoticed? Was she just ignored?
“It feels like she was abandoned.”