A GRIEVING husband believes the “inadequate” care of his mentally ill wife directly led to her “avoidable” death and has vowed to take legal action against health bosses.

Roger Colvin cannot understand why Teresa, his wife of nine years was not monitored more regularly by staff at the mental hospital where she had been admitted to 48 hours before she was found hanged using a telephone cord.

The 45-year-old from Lyndhurst was found slumped by the communal phone by nurses at Woodhaven. They discovered she was missing when they were carrying out 15-minute checks on her.

Southampton Coroner Keith Wiseman ruled that he could find no “systematic failure” in the care of Mrs Colvin – affectionately known as TJ – but said that the risk of the telephone unit within the acute mental unit was “underestimated” and a subject of “proper criticism”.

Southampton Coroner’s Court heard how Mrs Colvin began seeking help for her mental health in 2007 after revealing to her husband that she suffered serious abuse when she was a child.

She was diagnosed with severe post traumatic stress disorder. At its worst, she would hear voices in her head, hallucinate and try to harm herself.

She was admitted to Woodhaven on April 20, a year since her last stay, and was immediately placed on 15-minute observations. The hearing heard that during her stay staff failed to tell her husband about the severity of two incidences where she escaped the unit and the coroner accepted that Mr Colvin should have been fully informed.

In the hours before her hanging the hearing heard how Mrs Colvin had made several attempts to harm herself but 15-minute observations continued and it was at the 6.15pm check that she was found with the cord around her neck.

She died on April 26, at Southampton General Hospital, having suffered irreversible brain damage.

The coroner ruled that it was not clear if she had intended to end her life.

Despite Mr Colvin’s criticisms of the failure to increase the frequency of check on his wife the coroner ruled there was “no systematic failure” of care, particularly as Mrs Colvin had showed similar, if not worse, symptoms in the past when 15-minute checks proved sufficient.

Mr Wiseman said: “It is undeniable that Mrs Colvin died as a result of something that occurred when she was not being observed and in that sense the setting of those particular 15-minute intervals were clearly not protective enough.”

The trust has since shortened all telephones cords within all their sites.

But Mr Colvin insists that “the signs were clearly there” to indicate that she was at real risk of harming herself and believes that Southern Health NHS Trust, which ran the service that has since been closed, “fatally let her down”.

He said: “I have suffered a great loss that cannot be reversed.

“I have heard nothing that gives me any doubt that the risk assessment and the quality of management of my wife’s care over the weekend of her admission was inadequate and directly led to her fatality. Therefore this unfortunately does not allow me to reach closure and there is the need for me to pursue the matter further.”