The parents of a woman who overdosed on diet pills have blasted the "Third World" A&E conditions which led to her death as a coroner found there had been "serious failings" by the hospital.
Bethany Shipsey, 21, died on a hospital trolley having been moved three times in 20 minutes and her last words were "mum, mum, mum."
She had been left on a trolley in an overcrowded corridor before being seen by a junior doctor dealing with a drug he had "never seen before".
An inquest heard she swallowed pills she had bought online from Ukraine before texting a friend saying she had overdosed.
Today, Senior Worcestershire Coroner Geraint Williams exposed a series of failings in Bethany’s care as he recorded a conclusion of suicide.
Bethany was rushed to Worcestershire Royal Hospital – where she was on home leave from a psychiatric ward – following the overdose on February 15 last year.
Emergency junior doctor Alireza Niroumand admitted he should have referred Bethany to critical care hours earlier – but the department was full and he had been "too busy".
She was taken to a resuscitation room, but was moved to make way for others, and only had a tracheotomy for respiratory arrest when it was too late.
Following the hearing today, parents Doug, 52, and Carole, 57, slammed the hospital and said the Government were "complicit" in their daughter’s death.
Speaking outside Worcester Coroner’s Court, Doug said: "Beth did not intend to take her own life.
"In addition to the serious failings of the Worcestershire Royal Hospital, Beth’s life was brutally cut short by the effects of the deadly industrial toxic substance, which was illegally sold as a so-called diet pill.
"Beth was unlucky enough to be taken to an inadequate A&E department which was overcrowded, overwhelmed and under-staffed – literally a first world hospital in third world circumstances.
"Even in A&E Beth stood no chance of survival.
"During the inquest it became evident that a series of significant and serious failings led to Beth having a cardiac arrest.
"She died on the same trolley which she had been aimlessly wheeled around the A&E department, in and out of the resuscitation room, around the overcrowded corridors which were full of public view.
"No dignity, or privacy even in the final few moments of her life. Nothing was done to help save Beth’s life.
"Beth’s human rights were breached in the very place that you would most expect them to be preserved.
"'[This is] a system which is very broken."
Doug said that the Government blame winter pressures, but claims ‘this is happening all year round’ and added that "in any case, winter is no new phenomenon".
He added: "For as long as the situation is allowed to continue, the government’s failure to address it makes them complicit in all the harm and death caused to patients – not winter pressures.
"The hard working nurses and doctors are expected to work and function in the toughest of circumstances, and this undoubtedly leads to mistakes."
He warned about so-called ‘diet pills’ illegally sold online.
The father added: "Beth was a wonderful young person with her whole life in front of her but Beth has been cruelly taken from us and from her world."
Bethany, of Worcester, had been in the care of mental health professionals for two years but was not considered a suicide risk despite saying it was her fifteenth overdose.
She suffered from mental health issues after being sexually assaulted by her ex-boyfriend, Barry Finch, 23, who was sentenced to six years in jail in August 2016.
She had swallowed the pills just days after her psychiatric team found a bag of the tablets in her jacket and warned her about the dangers of taking them.
Recording a verdict of suicide, the coroner said: "Bethany was a young woman suffering with not insignificant mental health issues.
"She had for some time been under treatment on the Worcestershire Royal Hospital psychiatric ward. She had on several other occasions tried to take overdoses.
"It is appropriate for me to consider now whether she intended to take her own life.
"Whilst Bethany’s parents may not believe that, I find that it was the case.
"The A&E was very busy. It was overwhelmed. It was not that the staff could not cope, it just meant that it took them longer to deal with each patient.
"They were not understaffed but they did not have enough staff form the over capacity situation.
"Dr Niroumand said that Bethany needed to be observed. He spoke to her, and established that her purpose in taking the drug was to take her own life.
"Although he had not dealt with (the drug) before, he should have contacted the poison’s unit for guidance.
"This was a naive and unjustified decision on his part.
"Certainly making the call [to the poison’s unit] could have given him the opportunity to get guidance.
"This was a missed opportunity which would have been critical in potentially prolonging Bethany’s life."
When a young male was rushed to resuscitation room with a serious stroke it was decided that Bethany would be moved to a cubicle.
She was then seen by a nurse who recorded that the patient had appeared a little agitated and was hyperventilating, but failed to record this because she was "too busy".
The coroner claimed that this was a "serious failing" and led to a "critical failed opportunity to provide alternative care".
But he added: "I find as a fact that even if Bethany had received all of the treatments that were recommended she would on the balance of probability still have died.
"Further, her life would not have been prolonged due to the high toxicity of the drug.
"It might be right to say that there are failings, minor failings and serious failings, but these do not amount to gross failings.
"On the issue of overcrowding, in the A&E ward, I have been told that in the latest Care Quality Commission report noted an improvement in dealing with overcrowding."
At the end of the inquest, the coroner said he would write to the Secretary of State requesting the "sale and purchase" of the deadly drug is banned.
- Samaritans (116 123) operates a 24-hour service available every day of the year. If you prefer to write down how you’re feeling, or if you’re worried about being overheard on the phone, you can email Samaritans at email@example.com .