Health professionals missed opportunities to intervene in the case of a St Martins woman before she took her own life, a coroner has ruled.

Linda Constantine, 49, died on July 22 this year at her home in Cherry Tree Drive, days before she was due another mental health appointment with Meryl Jones, a community psychiatric nurse from Wrexham's Ty Derbyn.

Ms Constantine had previously had an appointment with Miss Jones on July 19 but failed to attend, with the nurse deciding – after waiting 10 minutes and leaving a message – that she would wait to see her a few days later.

Shropshire coroner John Ellery heard evidence from Vicky Constantine, the deceased's daughter, who said she flagged up in a phone call that she thought her mother was suicidal.

But Miss Jones decided not to order an intervention – a mental health assessment with two doctors and a social worker – as Ms Constantine had returned to work and was acting normally.

However, Mr Ellery criticised this decision, believing any moves towards a hospital admission for Ms Constantine should have been considered on the evidence of Dr Masood Malik, consultant psychiatrist/clinical director at Betsi Cadwaladr University Health Board (BCUHB), though admitting suggestions that it would have saved her life in future would have have been speculation.

"I am satisfied there is no other explanation for Linda than suicide," said Mr Ellery, who praised BCUHB for their response since the death.

He also stated he did not accept Miss Jones's evidence that hospital admission was not appropriate on the basis that Vicky informed her that her mother had been to a well-known suicide spot and that she was concerned Ms Constantine felt suicidal.

"Miss Jones denies that; she says that Vicky told her her mother had gone to the bridge but gone to work the next day and agreed to the plan of seeing in a few days.

"That tells me that she did not know the diagnosis of Linda and if I accept Dr Masood Malik’s view that that adds weight to the argument for hospital admission, plus knowing the history of Linda.

“If she didn’t know then she should have gone for hospital admission.

"She said that she was not suicidal on July 9 which may have been true but no basis to discount hospital admission due to fluctuating moods.

"The value of waiting for the next appointment after July 19 is outweighed by the evidence from Vicky."

Mr Ellery also criticised Miss Jones's practice of not taking notes in two phone calls with Vicky Constantine, although Dr Malik confirmed notes were not allowed to be taken to assessments and appointments by clinicians.

His summary also outlined three potential options that could have been available; that Ms Constantine be involuntarily or informally admitted, or a non-hospital decision.

But he added: "I am clear that the wrong decision was made, based on Dr Malik's evidence, but I cannot say what difference it would have made. It could have, but in this court, ‘could’ is not a fact.

"There was a missed opportunity that could have prevented Linda from taking her life. The hospital admission process could have been followed and I accept evidence that the criteria for that process was met."