WE have no excuse for this.

Those were the words from a Southern Health director after a coroner slammed the organisation for failing to submit a critical incident review after a woman jumped from the Itchen Bridge in Southampton.

An inquest heard how health officials did not intervene before Emma Connell was pulled from the river and rushed to A&E, despite having been admitted four times in the fortnight before.

On three separate occasions the 46-year-old had been found by police drunk, holding a knife to her throat, and even standing at the railings of the Itchen Bridge. During the last stint in hospital she absconded, despite doctors raising concerns with the state of her mental health.

Recording a verdict of suicide senior coroner for south Hampshire, Grahame Short, said: "The mental health services were involved on one of the occasions and, whilst I accept the problems of alcohol dependency, they were not able to help Emma as they should have done.

"I find it unacceptable Southern Health have not submitted a report and there are lessons to be learned from this."

Prof David Kingdom, a consultant psychiatrist and clinical services director for Southampton area mental health services, told Mr Short that Ms Connell showed no signs of suicidal thoughts when she was sober and they were unable to detain her under the mental health act when intoxicated.

"Suicidal actions are very common," he said.

"It's then a question of whether or not it was serious enough to warrant mental health visiting. What had been become very clear was that alcohol had been the major issue of Emma's problem. It's a complex process."

Mr Short said: "A decision was made that she was not at risk of her own life even though she tried to jump off the Itchen Bridge. In these circumstances does that not ring alarm bells?

"There is a death of someone in quite similar circumstances in Winchester. It's listed for Monday but I'm having to adjourn it again because I do not have these reports. Someone must be accountable for this: is that you?"

Prof Kingdom responded: "For Southampton, yes. There are a number of processes going through at the moment. That does mean there are delays but they should not be there to prevent you from having the most appropriate information available.

"We have no excuse for this. We're clearly very sorry and we're certainly trying to make sure we learn from what's happened."

In a subsequent statement from Southern Health a spokesman said: “We were deeply saddened to learn of the death of Ms Connell. She was known to our services and we had seen her on a few different occasions.

"Immediately after her death the Trust reviewed its procedures and has now changed the way it deals with people who present with similar conditions to Ms Connell.

"This includes always consulting the on-call consultant and making sure decisions on care are never taken alone.

"We also recognise the Coroner’s frustration at the delay in providing the Critical Incident Review report for this inquest. The Trust is reviewing its internal processes in an effort to make sure that this does not happen again.”

Ms Connell died at Southampton General Hospital on April 13 from a hypoxic brain injury less than a month after moving to a flat in Albert Road South.

The inquest heard how Ms Connell, who had recently returned to the UK after living in New York for 28 years, plummeted over 60 feet from the bridge on the eve before Easter Sunday - the 20th anniversary of her daughter's death.

Her death sparked a police appeal, published in the Southern Daily Echo, seeing a range of people come forward.

Statements from friends Dean Worsdell and Thomas Curtis read during the hearing confirmed they both heard a screech and a loud splash before seeing a dark figure in the water.