STAFF on a mental health ward at Royal Oldham Hospital missed 'a significant opportunity' to help a young woman with the drinking problem that killed her, a coroner has said.

Sarah McGarrigle, who started drinking as a teenager and at one time drank multiple bottles of gin a day, was found dead at home in Oldham on March 1, 2020, with 'catastrophic' internal injuries.

During the inquest into Sarah's death, Manchester North Coroner's Court heard how, the day before, she had been to Royal Oldham Hospital's A&E twice after throwing up blood.

She asked to leave the hospital both times against medical advice, and aware of the risk she might be dying.

But at the conclusion of the inquest on Monday, the coroner said it was a mental health ward where Sarah was sectioned in January 2020 that had the best opportunity to help her.

Catherine McKenna said the staff on Aspen Ward – which is run by Pennine Care NHS Foundation Trust – failed to make the most of the information available to them when making a decision to discharge her after a week in their care.

This information included the fact Sarah had a history of disengagement with health and social care and of neglect to her own health and wellbeing, as well as a tendency to leave her family's home in Liverpool and to return to Oldham, where she lived in isolation.

Ms McKenna said: "There was relevant clinical information available to the ward."

"This information was not taken into account when assessing Sarah's mental state."

However, Ms McKenna stopped short of saying the decision to discharge Sarah led to her death.

She said: "I need evidence to be able to say it is more likely than not that the death would have been avoided."

"The evidence does not show to the standard required that the death would have been avoided."

Also of concern to Ms McKenna was Aspen Ward's response to Sarah's death, which she called 'disappointing'.

Referring to one witness's evidence, she said: "It is rare for a witness to say that there is nothing to learn from a case, or that care could not have been provided in an alternative way.

"The court is disappointed with this response."

She said she intended to write to the chief executive of Pennine Care about her concerns.

Recording a narrative conclusion, Ms McKenna offered 'sincere condolences' to Sarah's family.

In response to the conclusion of the inquest, Clare Parker, executive director of nursing and deputy chief executive at Pennine Care, said the trust is making improvements as a result of Sarah's death, with more to come.

Ms Parker said: "We are very sorry that Sarah McGarrigle was unable to receive the mental health support she needed and we offer our deepest sympathies to her family for their devastating loss.

“We conducted a review at the time of Sarah’s death and also contributed to a safeguarding review with other agencies involved in Sarah’s care.

"As a trust we recognised that lessons could be learnt and we are making improvements – including improving the safety of our discharge processes and introducing new mental health capacity and self-neglect training for clinicians.

"Following the findings of the coroner we will now be completing a patient safety investigation to consider further areas of learning.”