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Mental health staff “missed opportunities” to check whether a young mother had access to the helium gas that killed her, a coroner has ruled.

Demi Williams, 22, died after inhaling helium at her Upper Holloway council flat. She was found dead by paramedics on March 15 – just 11 days after she left a non-secure facility for mental health patients.

An inquest at St Pancras Coroner’s Court heard that the former Highbury Grove pupil had been “sectioned” on January 10. During an assessment, she told staff at Highgate Mental Health Centre she had ordered helium gas as a means of committing suicide.

But this was not recorded, nor was Demi asked whether the helium had arrived after being given leave to return home. Her flat was not checked for the presence of the gas during a later visit by a staff member, the inquest heard.

After her death, police found an invoice at the flat dated January 6 for the purchase of a helium cylinder. It is not known when Demi took delivery of it.

On Friday, assistant coroner Richard Brittain said he was not satisfied beyond reasonable doubt that Demi had intended to take her own life. It remains unclear whether she had taken her anti-psychotic medication at the time of her death.

Recording a narrative conclusion, Dr Brittain said: “There were missed opportunities [by Camden and Islington NHS Foundation Trust] to consider the access Demi had at her residence to helium gas. Risk assessments that were undertaken demonstrated suicidal ideation but no plans. As such, she was not considered to be at increased risk of taking her own life.”

Demi’s family express­ed concerns during the inquest that mental health staff had not checked for the presence of helium at the flat, and that they had not been contacted at the time of Demi’s discharge. The trust insisted Demi did not wish her family to be involved.

When Demi’s body was discovered a DVD giving instructions on suicide was found among diary entries and random thoughts about suicide jotted down in a notebook, revealing she had done extensive internet research about ending her own life.

Chris Williams, barrister for Demi’s family, said it was “deeply concerning” that Demi had been able to get a copy of the video.

Dr Brittain said he will produce two reports to prevent future deaths based on the evidence heard at the inquest. One will be sent to the trust in relation to the helium issue. The other will be sent to the Directorate of Public Prosecutions in relation to the video.

Demi had turned up at Whittington Hospital A&E department on January 6. She was diagnosed with depression and psychosis, having suffered from “low moods” since at the age of 17 she had to give her baby son up for adoption.

She was given anti-psychotic drugs and recovered well, staying on voluntarily at the Highgate centre before moving to a non-secure facility in Drayton Park in February.

She was discharged on March 4, despite having expressed concerns about moving back to her old flat.

A spokesman for the health trust said: “In the period before her death we put in place a strong and clinically-appropriate care plan. This was supported with frequent risk assessments.

“We accept the coroner’s position on highlighting the potential harmful use of helium and will be taking steps to share this learning within the trust and more widely across the NHS.”