A woman who overdosed on diet pills intended to take her own life, a coroner has ruled.
Beth Shipsey, 21, of Worcester, died after taking the pills containing the substance DNP in February 2017.
Coroner Geraint Williams gave a narrative conclusion but said there were “significant failings” in care delivered by Worcestershire Royal Hospital.
The hospital trust said it was “sorry for the shortcomings” in its care.
The Shipsey family said the coroner’s conclusion “did not reflect the evidence” and they were considering the next steps.
They deny she committed suicide and said taking the pills was a “cry for help”.
The inquest heard how Ms Shipsey had an emotional personality disorder and her most recent psychiatric admission was in January last year. She was on home leave from the unit on the day she died.
She had previously taken 14 overdoses.
When she was treated at hospital in February, a doctor had “failed” to call the poisons unit over her condition.
The court also heard how a nurse failed to print out guidance on the toxicity of DNP which “delayed the onset of care”.
Mr Williams described this as another “critical failed opportunity”.
However, though these were “serious failures”, the coroner said they “became irrelevant” as “evidence suggests she would have died anyway”.
He said: “I find evidence that she wouldn’t have survived to be cogent and persuasive.
“Even if she had received all the treatment, on the balance of probabilities she would have died.”
Mr Shipsey said: “The coroner conducted a very deep and wide investigation.
“In these circumstances you do tend to grow a bit of a thick skin, but the emotions are always underneath.
“When you know what happened that night, because we relive it every day, and see people giving evidence, you think ‘that could have saved Beth’s life'”.