Sue Robdale, aged 60, of Kenwood Road, Copthorne, went missing from the Redwoods Centre in Shrewsbury on October 9, 2021, having climbed over a fence.
Miss Robdale had been moved from an adult acute ward to the Holly ward for over 65s despite having an abiding fear of dying alone and uncared for in a dementia ward.
She was found three quarters of a mile away in a pond off Mytton Oak Road, 28 hours later by a couple out walking on the afternoon of October 10. The cause of her death was recorded as drowning.
In reaching their unamimous conclusion of suicide, the jury also found that there were weaknesses in the transfer process when Miss Robdale was moved to the Holly ward. They also concluded that the likely risk of Miss Robdale absconding was "probably not" recognised.
Senior coroner John Ellery also concluded that a prevention of future deaths notice was not necessary. He found that the Midlands Partnership Foundation Trust service, which runs the Redwoods Centre, had taken action with more planned.
Mr Ellery said he wanted to be 'kept posted' on progress being made on the actions. He also said the trust had an 'open door' policy for families to approach them with concerns.
The jury had heard that the trust had already taken steps, including altering its observation intervals when patients are moved from one ward to another. A 122-page report had been presented by the trust on what lessons have been learned.
Mr Ellery had asked the jury to consider whether Miss Robdale's death could have been prevented in a reasonable way and without hindsight.
He said that no-one had 'escaped' from the unit by climbing the 6 ft 2 inch fence since the Redwoods Centre had replaced the Shelton hospital in 2012.
Miss Robdale was 5 ft 2 inches tall and could have stood on flower pots to climb the fence, the inquest had heard.
She had been considered the most appropriate patient to be moved when a bed had to be found for a new 16-year-old patient.
Mr Ellery said that the move had been "forced upon Sue due to external forces" and had a "negative effect" on her.
The inquest heard that the 48 acute beds at Redwoods serve a population of between 500,000 and 1 million people, and was under pressure.
The jury had heard that Miss Robdale, a retired occupational therapist, had been checked on an hourly basis when on Birch ward but could have been checked on randomly at between one and 15 minute intervals.
On the day when she went missing she had been checked at 10am but her absence was only noticed at 11am and the alarm was raised.
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