Deputy State Coroner Derek Lee said there was “ample evidence” an increased nurse to patient ratio was justified after the inquest heard Ms Raftery, 18, died in the intensive care unit after a “particularly busy” evening, when there were nine patients in the eight bed ward for a time.

It was clear that demands placed on staff the following morning, March 19, 2015, shortly before Ms Raftery died in her room, “prevented effective observation of Ahlia” to ensure her safety, Mr Lee found.

He rejected a submission by counsel for Hunter New England Health that there was no evidentiary basis to recommend Health Minister Brad Hazzard increase nurse numbers at Waratah’s Mater Mental Health Centre psychiatric intensive care unit.

The recommendation was “necessary and desirable”, Mr Lee said in findings released on Friday, after detailing a succession of failures linked to demands on staff that led to patient safety being “compromised” in the period before Ms Raftery’s death.

Mr Lee criticised “rigid adherence to policy” after evidence Ms Raftery was transferred between Hunter health facilities four times in the final five days of her life, including an “inappropriate” transfer from Lake Macquarie Mental Health Centre to the Mater unit simply because she was from Newcastle and not Lake Macquarie.

The transfer was “neither necessary nor reasonable”, Mr Lee found.

“The decision to transfer was not made by any member of Ahlia’s treating team but by a bed manager responsible for the administrative allocation of patients to wards,” Mr Lee said.

He recommended Mr Hazzard consider trials of pulse monitors on mental health intensive care unit patients in different parts of the state after evidence Ms Raftery was found dead in her room by another patient, and not staff who were engaged in handover activities.

Mr Lee recommended Hunter New England Health independently consider a trial of the monitors which are worn by patients and allow staff to track the vital signs of patients even when they are not visible.

Ms Raftery was on 15 minute observations at the time of her death but there was evidence she was not spoken to by a staff member for nearly four hours, although she was last observed by a staff member about 10 minutes before her death.

Mr Lee made a number of recommendations to improve procedures in Hunter New England Health mental health units, including that staff not “block record” patient notes where observations are recorded collectively some time after they are made, and that patients only be transferred with the consent of treating staff.

Mr Lee acknowledged an apology to the Raftery family made by Hunter New England Health on the first day of the inquest, and the health service’s commitment to improving deficiencies after Ms Raftery’s death.

Ahlia Raftery died one month after her 18^th birthday in an intensive care mental health facility “where she was meant to have been kept safe from harm”, Mr Lee said.