A vulnerable woman judged to be at medium risk of self harm was on a mental-health ward that catered for low-risk patients, an inquest heard.
Zoe Wilson, 22, died on the Larch Ward at Bristol's Callington Road Hospital in June 2019 after being found unconscious in her room at 01.30 BST.
She had previously told staff that voices were telling her to kill herself, her inquest heard.
Healthcare assistant Sarah Sharma found her and immediately called for help. Addressing a jury inquest at Avon Coroners' Court, she said that "patients admitted to Larch should have all been low risk".
This meant they would "preferably" have hourly observations by staff and be able to take their medication without any issues. Many were ready to be discharged and they were there because something was holding them up, normally housing, she said.
The experienced healthcare assistant said if the patient's risk increased they should be placed under "one to one" monitoring with a member of staff until they were moved to a more suitable unit.
The inquest heard earlier that Ms Wilson had been judged to be medium risk and was placed on 30-minute observations on 18 June.
Her risk level was re-assessed when she handed a belt to staff and informed them voices were telling her to kill herself.
Ms Sharma told the court that she was on her first overnight shift in two and a half weeks that night, and was informed in a handover that Ms Wilson was at risk of self-harming.
Having never met Ms Wilson - who had schizophrenia - she queried what kind of self-harm the patient was at risk of but said the nurse performing the handover told her he "didn't know".
Ms Sharma told the inquest she was unaware of the belt incident or that Ms Wilson had not been sleeping well and had requested medication to calm her down.
Source: BBC News, 24 January 2022
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