A "WONDERFUL mum" died from a brain injury after drinking too much water.
Michelle Whitehead passed away in 2021 after being admitted to Millbrook Mental Health Unit in Sutton-in-Ashfield, Notts.
An inquest into her death heard how on the afternoon of May 5, two days after being admitted, Michelle was excessively drinking water.
The condition, known as psychogenic polydipsia, is common in patients with psychiatric disorders.
But NHS staff on the unit failed to diagnose the 45-year-old with the disorder at the time.
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And she was allowed to continue having unsupervised access to water in her room.
Staff later administered her with tranquillisers to calm her down and she fell asleep, the inquest was told.
Michelle had in fact become unconscious and slipped into a coma.
But it took staff four hours to notice a change in her breathing and a further 15 minutes to put her in the recovery position.
Michael, Michelle's husband of 22 years, said healthcare staff should have realised something was "very wrong".
He told the BBC: "Had they acted earlier Michelle would have been taken to ICU [intensive care unit] and put on a drip.
"That would have saved her life."
Michelle was admitted to King's Mill Hospital.
The mum of two, from Rainworth, Nottinghamshire, died there on May 7, 2021.
Michael said the pair had met on a bus when he was 17 and Michelle 15 - they were together for 30 years and shared two boys.
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Michelle gave up her job as a nursery nurse when one of the couple's sons was born with Down's syndrome.
She was a full-time carer for 19 years before her death.
The inquest jury found on the balance of probabilities that she had died after becoming acutely over-hydrated.
This lead to severely low sodium levels, causing swelling in the brain, fatally injuring it.
Her medical cause of death was hyponatraemic encephalopathy, acute hyponatremia and psychogenic polydipsia.
Nottinghamshire Healthcare NHS Foundation Trust admitted eight failings in the care Michelle received while at Millbrook for the second time.
She was earlier admitted in 2018 following an acute mental breakdown.
The failings ranged from staff not adhering to trust policy when Michelle was tranquilised to inadequate observations as a result of being "distracted" by mobile phones.
The investigation into Michelle's death also found a 10-minute delay in letting paramedics enter the building.
Following the inquest, coroner Laurinda Bower sent a prevention of future deaths report to trust CEO saying more people could die "unless action is taken".
Ifti Majid, chief executive of the trust, offered his condolences and apologies to Michelle's family.
He told the BBC: "We are considering the findings of the jury and the coroner.
"We acknowledge that there were aspects of care which were not of the quality they should have been and will address the concerns raised so that the experience for patients now and in future is improved."
