A coroner has called for improvements at a high-security psychiatric hospital in Nottinghamshire after the death of a patient who swallowed a plastic crayon.
Tammy Watkins died in June 2021 after the crayon she ingested at Rampton Hospital perforated her bowel.
An inquest in October found neglect at the hospital contributed to her death.
A coroner has now called on hospital bosses to take action to prevent future deaths.
Ms Watkins, 36, had been assessed as being at high risk of ingesting foreign objects for self-harm and mechanical restraints, such as mittens, were in use.
But staff gave her a twistable crayon to use while her mittens were removed, which had not been risk assessed or approved for use, on 22 March 2021.
The crayon was noted as “missing” but no incident report was completed nor was a plan initiated to find it.
Ms Watkins presented with “symptoms of a complication of swallowing the item”, including vomiting, the following day.
The coroner’s prevention of future deaths report, published on Friday, says her symptoms were raised with the physical healthcare team and she said that she could “feel the twistable crayon inside her”.
However, she was not taken to hospital until 17 May 2021 after she told staff she had swallowed a toothbrush.
Ms Watkins had an x-ray at Bassetlaw District General Hospital but it did not reveal any foreign bodies.
Her symptoms worsened on 4 June 2021 but opportunities to seek medical attention for her were missed, said the coroner.
She died after suffering a cardiac arrest two days later.
Following the inquest, Ms Watkins’ family said they felt “let down” by hospital staff.
“It seems there were a lot of mistakes made by everyone at Rampton Hospital and a lot of warning signs that she needed proper hospital care,” they said.
Solicitor Jenny Fraser, who represented the family, added: “We hope that this investigation highlights to all establishments who have the responsibility of looking after those in need, to sit up and pay attention to ensure that they have the fundamental safeguarding and systems in place.
“Preventable deaths need to stop happening.”
Coroner Laurinda Bower said Ms Watkins’ death “demonstrates a further example of a failure by medical staff to recognise a deteriorating patient”.
She said this – and other deaths of ill patients in the care of the Nottinghamshire Healthcare NHS Foundation Trust – was “exceptionally worrying” and called for action “to be taken at the most senior level to effect meaningful change to the quality of physical healthcare across all secure settings at which the trust provides services”.
The trust has accepted multiple failings in the patient’s care “probably more than minimally contributed to her death”, the report added.
Ifti Majid, chief executive of Nottinghamshire Healthcare, said: “On behalf of the trust, I would like to say how deeply sorry we are to Tammy’s friends and family and once again extend our sincere condolences for their loss.
“We acknowledge that there were aspects of care which were not of the quality they should have been.
“We are considering the findings of the jury and any wider concerns the coroner may have, and will address these so that the experience for patients now and in the future is continually improved.”
The report comes after Rampton Hospital was rated “inadequate” by the Care Quality Commission following an inspection in June and July.
The trust will have 56 days to come up with an action plan after receiving the coroner’s report.