A sister of a woman who died after falling from a fourth-floor hospital landing has called for "systematic changes" after an inquest found a "significant gap" in her mental health care.
Anita Rooney (50), a mother-of-three from Dungannon, sustained fatal injuries in the incident at Craigavon Area Hospital on May 18, 2016.
The previous day she was admitted to the hospital as an in-patient after she was spotted at a bridge over the River Blackwater.
At the finish of a three-day inquest at Armagh courthouse, Coroner Joe McCrisken said that while Mrs Rooney's medical needs were "appropriately" treated on admission to the hospital's emergency department (ED) the day before her death, her mental health needs were not.
Afterwards Mrs Rooney's family members, including her husband Michael and grown-up children Thomas, Chloe and Natalie, urgently called for better services for vulnerable patients.
Her sister Noelle remembered Mrs Rooney as "warm, compassionate, humorous and kind", and stressed there is an "urgent need for systematic changes" in how vulnerable patients are treated.
The inquest heard how on the day of her death, Mrs Rooney fell to the bottom of a stairwell on the hospital's second floor, where medics - who were praised for their "exceptional" response by the coroner - rushed to help.
At the time the highly respected businesswoman, who had a history of mental health problems, had been reported missing from the acute medical unit (AMU), where she had been admitted as an in-patient from the emergency department.
The previous day at the ED she had been assessed as a "high risk of further self-harm" for deliberately misusing alcohol, a prescription drug and non-prescription drugs - items she had taken at a bridge over the River Blackwater.
She was spotted by someone who alerted the emergency services, who took her to Craigavon.
The inquest previously heard that no formal hospital risk assessment had been carried out on Mrs Rooney, although it had been arranged for her to see a consultant psychiatrist the day she died.
And in keeping with UK policy her physical medical needs were addressed first, which Mr McCrisken said meant that there was "period of 12 hours" when her mental state was "not addressed" from her initial arrival to Craigavon.
"She had been admitted to hospital in the first place as a result of mental ill health. This was not attended to, or treated within the ED," he said.
"This represents a significant gap in patient care which really must be addressed as a priority. On this occasion Mrs Rooney fell through a gap in services."
He did, however, find that staff at the AMU had appropriately treated Mrs Rooney, including following policy in alerting that she had gone missing.
A new risk assessment tool in the process of being rolled out at Craigavon was also welcomed by Mr McCrisken, who said on the "balance of probabilities Mrs Rooney had taken her own life".
He added that the changes implemented at Craigavon since the incident could be a "suitable legacy" for Mrs Rooney.
Afterwards Mrs Rooney's son Thomas called for more mental health care policies to help individuals like his late mother.
"Through our mother's death, we hope that changes can be made in regards to the way mental health is addressed and treated," he said.
"We believe that a breakdown in communication between the medical and psychiatric treatment which our mother received was a large factor in her death."
Paying tribute to Mrs Rooney as the "most generous and loving mother imaginable", he added that the family had endured a "struggle through the deepest tragedy possible".
"Our mother loved of all us dearly. We hope that we can move forward and look back fondly on the many wonderful and cherished memories that will always be with us."
The family thanked Packie O'Neill, who helped Mrs Rooney at the bridge.