“IF WE’D have known then what we know now about what happened at Southern Health, we wouldn’t have entrusted her to them.”

Those were the words of a grieving husband after a coroner ruled opportunities were missed to prevent the suicide of a Southampton woman at a mental health facility.

Maria Duarte, commonly known and ‘Joey’, died on January 19 last year after being found hanging in her room at Southern Health NHS Foundation Trust’s Antelope House.

As previously reported, the 49-year-old’s family questioned why staff did not watch over her more closely after she revealed she had thoughts about jumping off the Ikea building.

READ: 'Caring and loved' mum found hanged at Southampton mental health facility >>>

Winchester Coroner’s Court heard Mrs Duarte had been suffering from mental health problems for a number of years after issues in her childhood, and had been receiving treatment in Dorset for post-natal depression before moving to Southampton where she set up a catering business with husband Marco.

Daily Echo:

However, after a breakdown in the relationship which was later patched up, Mrs Duarte’s mental health problems returned, eventually leading to overdoses on her medication.

The inquest was told by DS Damon Kennard, of Hampshire police, an investigation was carried out following the death and a similar incident at Antelope House just a few months earlier in which 28-year-old Eleanor Brabant was also found hanging in her room. He found no criminality by Southern Health staff.

Laura Pemberton, director of nursing at the trust, said since both deaths a number of changes had been made, including door sensors to alert staff to hanging attempts.

Recording a conclusion of suicide, senior coroner Grahame Short said there had been “missed opportunities” and that the hourly observations Mrs Duarte was on were too infrequent, although he added: “I believe [15-30 minutes observations] would not have necessarily prevented her death.”

Following the inquest, Mrs Duarte’s husband Marco said: “We, the family, thought we were doing the right thing. We were not able to look after her and work at the same time, but we entrusted her to Southern Health. They failed us.”

Daily Echo:

Her sister Maria Catanho added: “I just feel justice wasn’t served today. I have lost my compass in life.”

Speaking on the steps of the coroner’s court, chairman of Southern Health Lynne Hunt apologised to Mrs Duarte’s family.

She said: “I am profoundly sorry that we were unable to keep Joey safe.

“An apology, set against the enormity of their loss, is totally insufficient but I offer one unreservedly to Joey’s family, and acknowledge that we did not involve them as closely as we should.

“Joey’s death has led to meaningful and ongoing changes to make Antelope House, and indeed all our whole trust, a safer place.

“We must all redouble our efforts to get this right first time, every time.”