Paragraphs 7 & 8 read: "'People thought that her paranoia might have been induced by cannabis,' says her father, 'but the diagnosis rapidly changed – first to schizophrenia and then to bipolar disorder,' the incurable cyclical condition once called manic depression."
"She was sectioned three times and spent eight months in a London hospital for the mentally ill. There were constant problems with her medication. 'It was just not working,' says her mother, 'and they kept on upping the doses.'"
Sixth & Seventh paragraphs from the end read: "He also wants smoking policy in hospitals and mental health institutions to be reviewed. Cigarettes are a familiar prop for many psychiatric patients. 'If you have psychotic patients gasping for a cigarette it is crazy to expect them to go out into the street to smoke, says Lord Dunboyne."
"'You must have a psychotic person in a place of absolute safety. It is no good 'accompanying' them outside, however good the supervising nurse is. Things can go wrong very quickly.'"
Mistakes, missed chances and a young life lost Genevieve Butler leapt to her death while in hospital after taking an overdose. Her father, Lord Dunboyne, tells Elizabeth Grice what must be done to prevent a repeat of the tragedy
Bright, attractive, generous-spirited: Genevieve ButlerThe plain facts of Genevieve Butler's suicide are terrible enough. She had asked to be taken outside for a cigarette.
As she went along the fourth-floor walkway at Chelsea and Westminster Hospital, accompanied by the mental health nurse who was looking after her, she broke free, clambered over the glass barrier and jumped to her death into the public atrium below.
Just before she fell, she dropped her head back, looked at the nurse and said "Goodbye". A few hours later she died of her injuries, aged 28 – the third mentally ill patient to commit suicide in this way at the hospital since it opened in 1993.
Behind this bleak final scene of her troubled life lies a sequence of events and lapses that exposes disturbing shortcomings in the care of the seriously mentally ill.
Though a bright, attractive, generous-spirited girl, Genevieve had a long history of mental problems, dating from the end of her time at university.
To her parents, Lord and Lady Dunboyne, it felt as though they were gradually losing the daughter they knew.
"People thought that her paranoia might have been induced by cannabis," says her father, "but the diagnosis rapidly changed – first to schizophrenia and then to bipolar disorder," the incurable cyclical condition once called manic depression.
She was sectioned three times and spent eight months in a London hospital for the mentally ill. There were constant problems with her medication. "It was just not working," says her mother, "and they kept on upping the doses."
But in her good phases Genevieve was able to hold down demanding jobs – she had a degree in economics and philosophy – and to live independently in a London flat.
Genevieve was pretty, with shoulder-length blonde hair, and she became so distressed by the side-effects of her anti-psychotic medication while at the hospital – hair loss, skin lesions and weight gain – that even after new drugs were prescribed, she was paranoid that her hair was still falling out and stopped taking them. Inevitably, she relapsed.
In the early hours of April 27 last year, during a depressive phase, she took an overdose of paracetamol. She awoke feeling sick and, having phoned for an ambulance, was admitted to Chelsea and Westminster Hospital. This is where, in hindsight, her story takes on a dreadful sense of avoidable disaster.
In the 33 hours between her admission and her death, Genevieve was never seen by a psychiatrist. She was assessed by two psychiatric liaison nurses who decided she met the criteria for admission.
But a junior member of the "crisis resolution team" decided that she was fit to be discharged for "home care" under supervision.
Lady Dunboyne, who was not told her daughter had attempted suicide until she arrived at her bedside, nor that she had not been taking her medication, was put in a desperate position.
"They had Genevieve under one-on-one observation," she says. "Yet they expected me to cover for them when in my opinion she clearly needed to be admitted. I was between a rock and a hard place."
Lady Dunboyne was in the ward when the nurse ran back to say Genevieve had jumped. In a state of near collapse herself, she found her daughter slumped on the floor.
There are no contemporaneous notes of the crisis resolution findings and no indication that Genevieve's mental capacity to understand her treatment options had been assessed. "It was a bank holiday weekend and they wanted her out on the Friday night," says her father.
"She was terrified that she would have to go back to the mental hospital.
Her time there" – from October 2004 to June 2005 – "was an extremely damaging experience for her and she was afraid of being sent back. That fear was almost certainly the origin of her suicidal thoughts."
It got worse. The inquest heard that there was no proper risk assessment of her condition and the notes of her previous psychiatric care were not consulted. The nurse responsible for Genevieve's final cigarette break had not been told that two other suicidal patients had leapt to their deaths from that spot.
If Dr Shirley Radcliffe, the coroner at Genevieve's inquest, had not chosen to give a narrative verdict – a simple, unvarnished statement of how she died and what happened in the hours leading up to her death – it is doubtful whether any of the inadequacies in procedure, and in the system itself, would have come to light.
Narrative verdicts, introduced in 2004, do not apportion blame and do not allow anyone to impute civil or criminal liability. But they can draw attention to defects in a system that should be addressed to prevent similar deaths in the future.
This one was unusually powerful. In the course of three handwritten pages, Dr Radcliffe said: "There was no risk assessment management plan in place before a treatment plan was devised. Despite the complexity of Miss Butler's illness and evidence of psychotic delusions of a persecutory nature, she did not undergo a formal assessment by an appropriate psychiatrist.
"We cannot say that it would have affected the outcome. But I do consider that it was a missed opportunity. If she had been sectioned earlier she might not have been allowed out for a cigarette."
Genevieve's parents, who have worked for 18 months to bring the issues surrounding their daughter's death to public notice, take a weary satisfaction from the narrative verdict. "It is no consolation to speculate on all the 'what ifs' and 'if onlys' that inevitably spring to mind from the verdict," says Lord Dunboyne.
"Genevieve is dead. She was the third mentally ill patient to die in the same way in this one hospital and there are probably other families throughout the country who are having to live with similar needless tragedies.
"We just hope and pray that the NHS will now do its best to prevent the same sort of thing happening to yet more people in need of proper psychiatric care in a place of safety."
The Dunboynes, who live in Rotherfield, Sussex, are deeply wary of presenting themselves as grieving parents making an emotional appeal. They will say little about their feelings or about what the loss of their daughter – the eldest of their four children – has meant to the family.
They focus instead on the system that let her down. They knew how she died. They were not trying to avoid or to achieve a particular conventional verdict. They were fighting to get the evidence into the open so that such a "chapter of disasters" could not happen again.
Lord Dunboyne urges that crisis resolution teams – dedicated to looking at possible alternatives to hospital admission for the mentally ill – should not be used as "gatekeepers" to the NHS's mental health units. "It is an area of government policy that needs to be examined very carefully," he says.
He also wants smoking policy in hospitals and mental health institutions to be reviewed. Cigarettes are a familiar prop for many psychiatric patients. "If you have psychotic patients gasping for a cigarette it is crazy to expect them to go out into the street to smoke," says Lord Dunboyne.
"You must have a psychotic person in a place of absolute safety. It is no good 'accompanying' them outside, however good the supervising nurse is. Things can go wrong very quickly."
Dr Radcliffe agreed with a previous coroner that it would be "inappropriate" to put up netting to stop people from jumping from the hospital's walkway, or to shackle patients to nurses. "There is no doubt that determined, resourceful and intelligent patients like Miss Butler are very ingenious at overcoming any barrier to committing suicide."
Chelsea and Westminster NHS Hospital Trust has just received a letter from the coroner outlining her concerns about the case of Genevieve Butler. "We will need to study it in detail to see whether action is needed," a spokesman said.
The Dunboynes looked after their daughter as long and as often as they could at their home.
They intervened to get her medication changed when she was at the mental hospital and they supported her when she was living independently – but they were no match, finally, for her illness or for the tragic way it was mismanaged.
• Papyrus is a national charity that helps those who live or work with suicidal young people. Their HopeLine is 0870 170 4000.