A woman died after choking on food while under intensive observation at a psychiatric hospital, an inquest heard.
Kirsty Thain, 36, from Wakefield, choked on a chip butty at Kendray Hospital, in Barnsley,
She had been regarded as high risk due to previous attempts to take her own life, including by choking, and staff had been instructed to keep her within arm’s length when she ate.
The hearing at Sheffield’s Medico-Legal Centre is due to last three days.
Laura Garfoot, of South West Yorkshire Partnership NHS Foundation Trust, said in a statement she had later been detained under the Mental Health Act and was transferred to Kendray Hospital.
On both occasions she had been on the highest level of observation and a member of staff had intervened.
On the day of her death, the jury was told she had been found trying to hide part of a veggie burger in her clothing and that she had attempted to choke herself twice before she choked on the chip sandwich.
Despite staff trying to dislodge the food and give her CPR, she was pronounced dead by paramedics, the inquest was told.
The court was told Mrs Thain had been involved in about 50 incidents of self-harm or suicide attempts while in hospital, 27 of which happened at Kendray Hospital.
Giving evidence, Det Sgt James Bailey, of South Yorkshire Police, said that on the day she died Mrs Thain had been wrongly given 125mg of pregabalin, five times her prescribed dose.
Side effects of the drug can include suicidal thoughts, he said.
However, he added that she had been seen by a doctor who concluded there had been “no ill effects” as a result as Mrs Thain had previously been taking up to 400mg a day.
Dr Piyush Prashar, the clinician responsible for Mrs Thain, told the hearing suicidal thoughts were a rare side effect and he did not believe the accidental overdose would have dramatically increased her risk.