A Henleaze mother, who had threatened to take her life, was not seen by a doctor despite being detained by police under the mental health act, an inquest was told.

Mother-of-three Katherine Waddington, or Katie as she was known, died at 3am on April 29, 2007.

A post-mortem found that Mrs Waddington, 34,who lived at Wellington Hill West, died from multi-organ failure as a result of combined paracetamol and alcohol in her system.

But confusion arose over an incident days before when police had detained her under the mental health act and took her to Bristol Royal Infirmary (BRI).

Tim Waddington, 32, a salesman, told the inquest his wife had suffered from depression and previously attempted to take her own life.

After an argument on April 25 Mrs Waddington had gone out. Mr Waddington knew that she had been drinking, had access to a large number of pills and had threatened to kill herself, so he phoned the police.

Three police officers located Mrs Waddington on Colston Avenue. They said they found her calm and controlled but were instructed by a superior to detain her under section 136 of the mental health act.

Coroner Terry Moore said under the act a detainee should be taken to a place of safety to be examined by a doctor. He said because of the suspected overdose officers took her to the BRI but that this was not a designated place of safety.

At the hospital Mrs Waddington was seen by a triage nurse – staff nurse Hayley Woodward – who was given background information but Mr Moore said it was "unlikely she had been given precise statutory details of the detention". He said: "There was then a miscommunication between the staff nurse and the police. The police officers believed erroneously that an examination had taken place as defined under the act, while the staff nurse believed Mrs Waddington was in the waiting room to see a doctor – the reason behind the section 136."

Mrs Waddington was taken to a friend's home and later back to her own home from which she made numerous calls to her husband and to her father, Chris Hennessy. The following day Mrs Waddington was found in a coma and never regained consciousness.

Mr Moore said it would be easy to criticise the reasons behind implementing the section 136 but that the section had not been followed through to its conclusion. He said: "Katherine Waddington died in hospital following an overdose of tablets and alcohol after having been released from police detention under section 136 of the mental health act before a mental health assessment was carried out."

Chief Inspector Hilary Martin, of the Police Professional Standards Department, said: "We extend heartfelt condolences to the Waddington family and to Mr and Mrs Hennessy. The police officers concerned have been very affected and upset by this. At all times they believed they were acting in Katie's best interests. This was a very unusual set of circumstances, we are improving our systems and procedures to ensure we work effectively with hospitals under the mental health act."

"The actions of the police officers was examined by the Independent Police Complains Commission which, while accepted the shortcomings of the officers, found them to have acted throughout with integrity trying to act in the best interests of Mrs Waddington."

A statement from Mrs Waddington's mother Patricia Hennessy read out in court said: "I feel totally numb about the whole situation. I am sure she did not need to die, she had three children. I do not think she would have wanted to leave them for one minute."