Cerys Lupton-Jones pauses between two doorways. One door leads into a side room in the Manchester mental health unit where she's a patient. The other leads into a toilet.
The 22-year-old had tried to end her life just 20 minutes earlier - but no staff are seen on the CCTV footage from inside the unit.
She hesitates for about 30 seconds, walking backwards and forwards. Then she enters the toilet and shuts the door.
The next time she is seen on the footage, doctors and nurses are fighting to resuscitate her.
Cerys dies five days later, on 18 May 2022.
A coroner has concluded that some of the care Cerys was given at Park House, which was run by the Greater Manchester Mental Health NHS Foundation Trust, was a "shambles".
Staff were meant to be checking on her every 15 minutes.
But the last recorded observation - at 15:00 - had been falsified, saying she had been seen in a corridor. CCTV shows at that point, Cerys was already in the toilet where she would fatally harm herself.
A staff member who was supposed to be looking after her has now admitted to falsifying these records.
Zak Golombeck, coroner for Manchester, said that if someone had stayed with her after the earlier attempt to take her life, what followed may never have happened. He said neglect was likely to have contributed to her death.
Campaigners are calling for an inquiry into the number of deaths at the mental health trust and believe the services are in crisis.
Greater Manchester Mental Health Trust said it "failed her that day, and we are so very sorry that we did not do more".
Source: BBC News, 21 October 2025
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