A missed opportunity to prevent a young woman from leaving hospital hours before she fell from cliffs contributed to her death, a coroner has concluded.

Rachel Garrett, 22, died after leaving the emergency department at the Royal Sussex County Hospital in Brighton and falling from nearby cliffs.

The coroner expressed her concern that hospital staff may not have been able to stop Rachel from leaving the ward in time due to the powers available to them.

Penelope Schofield, senior coroner for Brighton and Hove, delivered a narrative conclusion which included that Rachel had committed suicide.

In her concluding remarks, Ms Schofield said: “Rachel’s family couldn’t have done more to support their daughter. They wanted to do their best for their daughter but they just didn’t know what else they could do.

“There was a missed opportunity to prevent her from leaving the Royal Sussex County Hospital for the second time.”

The Argus: Rachel GarrettRachel Garrett (Image: Family handout)

Mrs Schofield said that because only certain staff are allowed to use "holding" powers in emergency departments there could be delays in these powers being put into action.

She added: “In the fast-moving world of A&E this causes me a concern as I cannot foresee that these doctors would be immediately available to assist should a mental health patient abscond.

“We are still left with difficulties that staff are faced with in having to get a doctor who may have no knowledge of the patient and who is very likely to be engaged with another emergency patient to make a quick decision around holding a patient under section 5(2) [of the Mental Health Act].

"I’m afraid that I take the view that by the time this is done the patient will be long gone.”

The coroner accepted, however, that this was an issue nationally and commended hospital staff for beginning to implement changes.

Rachel, of Brunswick Square, Hove, died after falling from cliffs in Brighton Marina on July 29, 2020.

The inquest heard how the young woman, a student at Bath Spa University, had suffered with mental health problems for a number of years and had attempted suicide five times in the four weeks prior to her death.

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Earlier in the hearing at the Leonardo Hotel in Stroudley Road, Brighton, the court was told that Rachel had been taken to the Royal Sussex County Hospital after being found on the cliffs on July 28, but absconded after spending time in the emergency department.

After subsequently being returned to the A&E department on the morning of July 29, Rachel absconded again and returned to the cliffs where she died.

Rachel’s parents Andy and Sarah Garrett described their daughter as the “joyful, beating heart” of their family.

The Argus: Rachel performing with grasshopperRachel performing with grasshopper (Image: Family handout)

They said she was a creatively talented woman who played drums in the Brighton-based band Grasshopper who played at the Isle of Wight festival and Kendal Calling.

The coroner said she would be seeking a Prevention of Future Deaths report covering who should employ mental health nurses who can use holding powers.

Reacting to the conclusion of the inquest, Rachel's father Andy said: “It’s a mixed feeling really, we are very pleased about the Prevention of Future Death report we think that’s of huge significance and hopefully beneficial to other people and will hopefully save lives.

"That feels hugely significant and important and that Rachel will have some form of legacy at least."

Mum Sarah added: "Rachel was very joyful, she had a fantastic sense of humour and she made and kept groups of friends.

"She really wanted to give back and we had great faith that she could crack her illness with the right treatment."

Currently, only staff employed by the “acute trust” [the trust running the respective hospitals] can use holding powers.

In Rachel’s case, while University Hospitals Sussex NHS Foundation Trust run the Royal Sussex County Hospital, the mental health nurses able to enact the holding powers are employed by Sussex Partnership NHS Foundation Trust.

The Prevention of Future Deaths report has been delayed for six months in order for the trusts to be able to continue to enact changes currently being implemented.

Sussex Police, University Hospital Sussex NHS Foundation Trust, Sussex Partnership NHS Foundation Trust and the Independent Office for Police Conduct all expressed their condolences over Rachel's death.