A WOMAN found drowned in a stream had been tragically failed by a hospital in Wales, an inquest heard.
The body of Tracey Jane Murray was discovered in a stream in Bodelwyddan, Rhyl, Denbighshire, on April 1 last year, after leaving nearby Glan Clwyd Hospital without being discharged on March 30.
Miss Murray, aged 44, from Radstock Close, Sharples, was being treated after an overdose on a surgical ward.
The Betsi Cadwaladr University Health Board (BCUHB) admitted during an inquest in Wrexham it had failed Ms Murray.
Matthew Makin, executive medical director of BCUHB, said there was an intention to refer her to the psychiatric team, but that was never done.
He told the inquest: “We fell short in meeting her psychological needs.”
The inquest heard that Miss Murray had suffered from agoraphobia and underwent a hysterectomy following a misdiagnosis of ovarian cancer.
She had struck up a friendship with Top Gear presenter, James May, on Twitter.
She walked out of the hospital where she was being treated following an overdose and was found two days later drowned in the stream.
Mr May, who co-presents Top Gear with Richard Hammond and Jeremy Clarkson, said in a statement read to the inquest that Miss Murray blamed the medical profession for her plight.
He said he started to correspond with Miss Murray on Twitter after she joined a discussion about poetry.
Mr May described Miss Murray as being well read and said she could be fun but also said she was a “soul in some torment”.
At one point Miss Murray’s sister, Shirley Reynolds, of East Renfrewshire, accused the health board of negligence, but North East Wales and Central Coroner John Gittins stressed that was not a matter for the inquest to decide.
Mr Gittins also emphasised there was no way of knowing what the outcome of a psychological assessment on Miss Murray would have been.
He expressed concern that, nearly 12 months after her death, the health board still had not fully implemented operating policy revisions.
Mr Makin said it was an ongoing process, although protocols were in place and they were currently in draft form. He expected everything to be ready within about six weeks.
Following Miss Murray’s death, a serious incident review took place. On the issue of referrals to the psychiatric team, steps had been taken, including mandatory staff training.
Miss Murray’s absence was reported to hospital authorities and a decision was made not to go after her. A post-mortem exam-ination carried out by Dr Andrew Dalton found Miss Murray had died as a result of drowning.
Recording an open verdict, Mr Gittins said: “She was a young woman who came to a tragic end in circumstances where she felt partially abandoned.”