Shannon Quinn, 24, was found hanged at Oak House mental health rehabilitation unit, in Tipton, on January 9 last year after staff missed a critical five-minute check.
The inquest found gross failings were a “direct contributory factor” in her death
Black Country senior coroner Zafar Siddique then wrote to several organisations with concerns over what happened to the former fine arts student.
Miss Quinn suffered from Asperger’s Syndrome, anxiety, depression and had an emotionally unstable personality disorder.
In his report - sent to Oak House operator Camino Healthcare, the Health Secretary, the Care Quality Commission, and Birmingham and Solihull Mental Health Trust - Mr Siddique raised concerns about a lack of information-sharing by agencies involved in her care, and the failure to train Oak House staff in how to deal with her complex psychiatric condition.
The report stated: “In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.
“All agencies involved may wish to consider reviewing their approaches to sharing of multi-disciplinary/agency medical notes and risk assessments for community patients with these complex needs.
"Oak House may wish to review its ligature and risk assessment policy and also their policy in determining which patients they should admit as part of their pre-assessment process. They should also consider reviewing their first aid training for all staff including CPR training.
"The mental health trust may wish to consider reviewing their policy in discharging patients with complex medical needs as in Sarah Quinn’s case without a community treatment order in place. The CQC may wish to further review the provider, Oak House and consider whether further inspections are necessary.”
There were also concerns that Miss Quinn had been given accommodation miles from her Solihull home resulting in her concerned family facing a £70 round-trip taxi ride to visit.
Help and advice for those having a mental health crisis is available from a number of agencies including: