A Liphook woman who choked on a sandwich while being treated at a mental health hospital died as a result of inadequate care, an inquest jury has concluded.

Tracy Ann Young, 54, suffered a catastrophic brain injury after choking on food at Parklands Hospital in Basingstoke on February 18, 2025.

An inquest at Winchester Coroner's Court heard that staff responsible for observing her had failed to meet required standards, with some using their mobile phones while on duty.

Ms Young, who had bipolar affective disorder, was being treated on Cherry Ward and had been due to move into a seclusion room.

However, no beds were available and she was instead placed in a de-escalation room, where staff initially carried out one-to-one observations before increasing supervision to two-to-one.

The inquest heard that observation standards were not met for several reasons, including staff using their phones and restricted visibility into the room.

CCTV evidence presented during the hearing showed staff looking at their mobile phones while they were supposed to be monitoring Ms Young.

On February 18, she had concealed a sandwich in the room and began eating it without staff noticing.

She subsequently choked and collapsed, with her airway becoming blocked and depriving her brain of oxygen.

The court heard that three minutes passed between staff discovering her unresponsive and the start of cardiopulmonary resuscitation (CPR).

Ms Young was taken to hospital in Basingstoke, where she remained for more than five weeks after suffering a hypoxic brain injury.

She was transferred to St Michael's Hospice on March 26 and died four days later, on March 30, with her mother at her bedside.

The inquest, which examined the circumstances surrounding her care and the actions of staff responsible for monitoring her, concluded on Monday, October 19.

Returning its findings, the jury stated: "Tracy's care lacked in significant areas."

Her medical cause of death was recorded as hypoxic brain injury caused by choking on food.

The jury concluded that her death was the result of misadventure due to inadequate care.

The findings followed evidence about failures in the supervision of a vulnerable patient who had been placed under enhanced observation.