A mental health centre has been slammed for “multiple failings” in caring for a mother with a “heart of gold” who cut herself and was found bleeding to death by another patient in the facility’s car park just moments after she reportedly spoke to a member of staff on the ward.

Mother-of-five Emma Butler, from Prestwood, died while she was sectioned as an in-patient on the Ruby Ward at the Whiteleaf Centre, in Aylesbury.

She was found with deep wounds to her forearms and had lost up to an estimated two-fifths of her blood after being discovered late in the afternoon on March 28 last year.

The jury, at an inquest held into her death between November 21 and December 6, was reportedly critical of the care and decision-making which allowed her unsupervised leave on the day of her death despite evidence of her risk of self-harm.

Emma’s family’s lawyers said the jury found that the change of approach to granting Emma the leave and Emma’s taking it “probably” contributed to her death.

The jury is also believed to have identified that the change of approach to the care and discharge planning for Emma while an inpatient on Ruby Ward during 2017 and decisions about the leave granted on the afternoon of March 28, 2017, “possibly contributed in more than a minimal or trivial way” to her death.

On the day of her death, Emma was granted unsupervised leave for one hour. Lawyers Leigh Day said this was despite ongoing events of self-harm and psychotic thoughts.

She was later found in the car park of the Whiteleaf Centre having seriously self-harmed. She was transferred to hospital in Aylesbury and went into multiple organ failure, being taken off life support on March 30.

Senior coroner for Buckinghamshire Crispin Butler reportedly noted that there was no evidence that Emma intended to take her own life.

The family’s lawyers said during the inquest it emerged that Emma had called the Ruby Ward telephone 15 minutes before she was found with the fatal injuries and, despite this call lasting for one minute and nine seconds, it failed to appear in any of Emma’s medical records and her family still do not know which member of staff answered the call.

Emma had a history of mental ill health and serious self-harm and was diagnosed with depression when she was 15. Following a five-year period of stability, Emma was diagnosed with Emotionally Unstable Personality Disorder.

Leigh Day said although Emma engaged with the clinical team on the ward, she continued to self-harm, adding that serious issues had been highlighted around the care provided at the Whiteleaf Centre following the deaths of three inpatients – 19-year-old Zoe Watts, former Amersham rugby player Jack Portland and Ms Butler – within a 15-month period.

Ms Butler’s family said: “Emma was beautiful on the inside as well as the outside. She had a heart of gold and would help anyone she could when she was well enough to do so. She was a warm, loving person with a good sense of humour.

“Emma’s children were her world and she absolutely adored and loved each and every one of them. She is very deeply missed.

“The jury’s conclusion confirms what we have known about Emma’s care for the last 20 months. We hope that the trust now makes the changes required so that no other family has to go through what we have had to go through.”

Sophie Wells, solicitor at Leigh Day said: “We are grateful for the diligence of the jury and for their recognition of the multiple failings in Emma’s care which contributed to her very sad death while an inpatient at the Whiteleaf Centre.

“Inquests are incredibly distressing for any bereaved family, however Emma’s family had to endure a prolonged hearing after it emerged their daughter’s call to the ward before she was found with fatal injuries had been answered and lasted for over a minute. Emma had said she would call the ward if she needed support.

“Although it is deeply unsatisfactory that no staff member can recall receiving Emma’s call, her family and I hope that changes will now be made that better protect other patients in the future.”

Oxford Health NHS Foundation Trust, which the centre is a part of, said: “We would again like to offer our condolences to Emma’s family and friends.

“We contributed fully to the inquest proceedings and we have taken note of the Coroner’s jury’s findings.

“Following Emma’s tragic death we commissioned a review of the circumstances surrounding her care and treatment, led by an independent expert.

“All the recommendations from this review have been accepted, actions on most are complete and others are underway or ongoing. Should the coroner identify any other areas of concern, we will seek to address those as a matter of urgency.

“In all such cases we strive to understand and apply any learning – in order to reduce the likelihood of any recurrence, and to improve the care and treatment we provide to the people we serve.”