A mentally ill patient was left hanging by a sheet from his upturned bed while a nurse waited for the arrival of someone else before entering his room, an inquest heard.

Nursing supervisor Marlene Taylor was working the night 35-year-old Shandal Richardson was found dead at the Mid Atlantic Wellness Institute (MWI).

The father-of-three was admitted to MWI on March 4 last year after trying to stab himself with a knife at his Southampton home.

He was deemed to be a suicide risk by an Emergency Room doctor at King Edward VII Memorial Hospital before being admitted to MWI where he was placed in the acute care Somers' Annexe.

Initially Mr. Richardson was placed in a room at MWI used for "observation and seclusion", which only had a bare mattress and a urinal bucket. However, he was moved to a different room before his death, meanwhile another patient who attacked nurses was put in the seclusion room.

Yesterday, the inquest heard that Mr. Richardson was found hanging from his upturned bed shortly after 2 a.m. on March 5. Ms Taylor was the person who found Mr. Richardson.

She told the inquest she heard a banging from one of the patient's rooms. She looked into two rooms before heading to Mr. Richardson's room.

She told Coroner Juan Wolffe she was unable to see fully into his room because something was obstructing the doorway. All she could see was his roommate waving for her to come in, an upturned bed and the top of Mr. Richardson's head. She said she did not notice a sheet attached to the bed post and Mr. Richardson's neck at that point.

Instead of going into the room Ms Taylor went back to the nurse's desk to call assistance from another nurse who was on break at the time. She told the inquest MWI's policy was for two nurses to enter a room for safety reasons.

When asked by Mr. Richardson's family's lawyer Victoria Pearman if the policy included emergency situations, Ms Taylor replied: "It depends on the emergency."

Ms Taylor added that she did not activate an alarm, which would have called for a number of personnel to rush to the wing, because she was not sure of the situation.

"I didn't know what was going on in the room when I saw the bed upright," she told the inquest. "I didn't know if [his roommate] had done something to him. At that point suicide did not cross my mind."

It took 30 seconds for a fellow nurse to arrive, she said. When they opened the door Mr. Richardson's roommate left the room before the nurses entered.

Ms. Taylor's described the scene to the inquest, including members of Mr. Richardson's family who cried at times.

"When I entered I saw Mr. Richardson with a sheet tied around his neck dangling from the bed. He was in a slumped position," she added.

Previously the court heard that Mr. Richardson was still alive when the nurses entered the room and was seen frothing at the mouth, he was later pronounced dead at the King Edward Memorial Hospital.

The inquest will hear more from Ms Taylor on November 19 when it resumes.