A patient considered chronically suicidal and who was checked every 10 minutes by nurses left her hospital ward and drowned herself on Weston beach, an inquest heard yesterday.

Susan Flower made the one-mile journey, walking out of the Juniper Ward at Weston General on July 14, 2010 at around 10.05pm.

The mother-of-two, 60, of Nailsea, was recovered by the Coastguard shortly before midnight but despite medical efforts died in hospital.

After discovering she had gone, staff carried out a 20-minute search of the wards and grounds before reporting her disappearance to police an hour later.

But an inquest at Flax Bourton yesterday heard that the hospital had followed all procedures correctly and that as an “informal” patient Mrs Flower, who had attempted suicide on several previous occasions, was not under any obligation to remain on the psychiatric ward.

Staff giving evidence at the inquest said despite Mrs Flower’s history, her behaviour had given them no cause for concern that she would try to leave the ward or take her own life.

The ward’s charge nurse Kate Sloan told the inquest: “If I thought for one minute that she was going to leave the ward and harm herself I would have put her on an even higher level of observation.”

Modern matron Jon Williams said since Mrs Flower’s death the hospital had made significant changes to policy including implementing air locks on the doors, improved observation forms and had erected a larger fence on the perimeter of the garden to prevent escape.

Avon Coroner Maria Voisin recorded a verdict of suicide.

After the inquest Mr Flower, 78, who had been married to his wife for 15 years, said: “I am not satisfied. I feel deep down inside that she could have been saved.

“I feel that they could have acted quicker when they realised she was missing. They have now made improvements and while they can’t save Susan I’m glad they have as it may stop someone else getting out and taking their own life.”

A spokesman for the Avon and Wiltshire Mental Health Partnership Trust said: “The Trust’s thoughts and best wishes are with the family and friends of Mrs Flower.

“As the court heard the level of care offered by our staff to Mrs Flower was considered appropriate and no criticism was made of the Trust.”