Hospital failings continued after Alice Figueiredo death, leaked documents show

"The similarities between this young woman and [Alice Figueiredo] are startling in terms of presentation, age range, background," the email said.

It goes on to say while it appears there has been "some learning" since Alice's death, there was "significant evidence" that not all incidents were being properly reported.

The hospital used an NHS risk management system called Datix where incidents should be logged on the system to help identify risks and patterns of behaviour.

The report says during the time Alice was on the ward there were 81 incidents or near misses that met the criteria for being reported via Datix, but just 14 (17.2%) were logged on the system.

In the November case, there was also significant under-reporting. The report suggests that of 45 self-harm events involving the unidentified young woman, 27 do not appear on the risk management system, including the attempt to harm herself using a bin bag.

The general lack of recording on the ward meant "opportunities to safely manage patients were missed", the inquiry found.

NELFT says it has removed plastic bags from wards in line with national guidance, and improved record-keeping and case management.

Overall, the internal report paints a picture of a ward where there were very sick patients, staff shortages - particularly of nurses - and a poor relationship between ward manager Benjamin Aninakwa and the consultant psychiatrist.

The report also says 100% of the support workers assigned to observe Alice one to one were temporary staff.

Brian Dow, from the mental health charity Rethink, says the document shows the unit did not act quickly enough after Alice's death to protect other patients.

"Lessons should be learned, and you should not expect to see a repetition of the same risks and the same dangers just weeks afterwards," he said.

"You need to have a culture of openness and transparency so that you can learn from the mistakes."