A GRIEVING father broke down in tears as he explained how his family felt let down by a system which had allowed his 23-year-old daughter to abscond from a psychiatric unit and drown in a nearby reservoir.
Edward Jordan made an emotional plea for action during the inquest into the death of Lisa Marie Jordan at which an open verdict was recorded.
"I don't know why she is dead. We do have serious misgivings about her treatment, although we don't want to point the finger at any individuals," he said.
"In the circumstances we found ourselves in we tried to do our best for Lisa but found there was very little help available.
"We feel the system let both us and Lisa down and somebody must be able to do something about it."
Lisa, a carer, of Blackburn Road, Accrington, was taken to Blackburn Infirmary by her concerned parents on November 20 and was later admitted to the psychiatric Unit at Queen's Park Hospital, Blackburn, as a voluntary patient.
She was sectioned under Section Two of the Mental Health Act on December 3 after breaking a window and going missing from from the unit for 30 minutes.
She had been under constant, one-to-one care, when two days later she put on her shoes at 5.55pm and ran out of the ward.
A major police operation was launched and her body was discovered in Guide Reservoir, Blackburn on January 3. GP Dr Arthur Manuel said he had first spoken to Lisa about her problems and inappropriate behaviour in September 1998. He added: "She admitted she had been involved in illicit drug taking, with magic mushrooms, LSD and amphetamines, and had been confused about her sexual orientation.
"The second time I saw her she said she was trying to organise her life and gave no suggestion of self harm."
Dr P T Saleem, consultant psychiatrist treating Lisa, said she suffered from sudden psychotic episodes and her behaviour was very unpredictable.
On many occasions she went into a stupor, during which she was unresponsive.
She had no previous history of overdoses and had never admitted to any suicidal tendencies.
"The only documentation that she had any tendencies was to a social worker when she said she'd thought of drowning herself as she put her head under running water," said Mr Saleem.
"She was very inconsistent and because of her changing behaviour this could have been messing around or serious. I believed she showed the classic signs of schizophrenia but, as any good doctor would, I was keeping an open mind."
Janice Saddington was the staff nurse giving one-to-one care when Lisa went missing. She said after spending 25 minutes in the toilets Lisa went back to the female dormitory, put on her shoes and broke into a run as she went towards the day area.
"I was slightly behind her following her, but I couldn't catch her and when I opened the doors I couldn't see her.
"It was dark so I went to get help," she said.
The family said they had expressed concern to medical staff and social workers about the care Lisa was receiving and were worried a diagnosis may have been made too early into her treatment.
Her sister, Christine Grimshaw of Taunton, said: "Lisa was a very happy, sociable, thoughtful caring person with lots of friends.
"She was loved by them and her family.
"The Lisa you are hearing about now is not the Lisa we all knew and loved.
"This was the Lisa of the last three months of her life."
Converted for the new archive on 14 July 2000. Some images and formatting may have been lost in the conversion.
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