A CORONER has called for improved measures to be introduced in hospitals to prevent mentally-ill patients absconding and putting themselves in danger.

Devon coroner Dr Elizabeth Earland was speaking at the end of an inquest into the death of Daniel Heard, 26, a schizophrenic who disappeared from the Cedars Unit in Exeter in February 2004. His body was found a week later.

The jury at the inquest returned a narrative verdict, stating that Mr Heard died in the late evening of February 24, 2004, the same day that he left the unit.

Dr Elizabeth Earland made a number of recommendations which included the use of swipe-card locks. She also suggested data on people absconding be made publicly available and called for nurses who could recognise a patient to accompany search teams.

Dr Earland also suggested more care records be kept, risk assessments recorded, and a comprehensive training programme be created for those entering the unit.

She told the inquest: "I and my officers, and anyone involved in this case, very much hope Daniel Heard's death has prompted lasting change that will help those that come after."

The inquest at Exeter County Hall had heard Mr Heard, from Tiverton, had been diagnosed with schizophrenia in 1996 and spent several spells in the Exeter psychiatric unit.

His final admission had been on February 13, 2004. Although he was not allowed to leave the unit, he absconded 11 days later. A police search did not start until five days after he went missing. His body was discovered by a passer-by.

He was dressed in a shirt, jeans and trainers. In the five days he was missing temperatures had plummeted below freezing. Two pathologists said hypothermia was likely to have been a factor in his death.

Last night Mr Heard's mother, Lynda Kelly, criticised the health trust that was taking care of her son.

Her legal representative, Richard Stevinson, said despite the inquest lasting nearly five weeks, it had not been possible to establish some facts leading to Mr Heard's death. He said this was partly due to documents withheld by Devon Partnership NHS Trust, nurses involved not giving evidence and a delay in opening the inquest. He said: "It is often the case, as it is here, that justice delayed is justice denied."

He said: "Mrs Kelly is not convinced the trust has taken significant steps in the intervening period of nearly five years to improve the system of monitoring doors to the unit. On so many different levels, Daniel Heard's death was avoidable."

But Devon Partnership NHS Trust said it had improved, but a balance was needed between security and patient freedom.

Trust chief executive Iain Tulley said: "Psychiatric units are not locked areas. We have to balance the rights and liberties of some patients against the needs of others. We will continue to look at the security arrangements and look at minimising the risk of such a tragedy happening again."

Devon and Cornwall Police has previously apologised for its mistakes made in the search, adding it had made significant changes.