A woman who was groomed and sexually abused in Rochdale took her own life after being removed from a hospital bed before a mental health review, an inquest into her death concluded.
Charlotte Tetley, 33, had suffered a deterioration in her mental health after a decision to remove her from an inpatient bed list on June 25 last year, Sarah Murphy, assistant coroner for Cheshire ruled.
Ms Tetley died in Macclesfied, Cheshire on September 24, 2024.
Her inquest, earlier this month, at Cheshire Coronerâs Court in Warrington, heard she had a complex longstanding mental health history and was a victim of the grooming in Rochdale, suffering âsignificant sexual abuseâ.
She had been under the Macclesfield Community Mental Health Team since July 2023 when she moved from Rochdale after her abuser returned to the area.
Ms Tetley had been diagnosed with an emotional unstable personality disorder and had previously been diagnosed with post-traumatic stress disorder and substance misuse causing behavioural and mood disorder, using drugs as a coping mechanism.
On June 18, last year she attended the accident and emergency department at Macclesfield Hospital voicing concerns for her safety and thoughts to jump in front of a train.
But six days later medics decided she did not need a mental health inpatient bed though Ms Tetley herself felt the only option for her to get better was for her to continue as an inpatient.
The next day, Ms Tetley, who was homeless, was discharged before an attempted review by a mental health specialist.
She later engaged with the community mental health team and community drug services, but on September 18 last year, was removed from railway tracks by British Transport Police and taken to the accident and emergency department of Macclesfield Hospital.
She had reported feeling suicidal to workers who had found her, but she left the hospital before being reviewed by the mental health liaison team.
On the morning of her death, September 24, she spoke with her mental health keyworker and expressed longstanding suicidal ideation without immediate intent.
Ms Tetley also attended the office of the community drug and alcohol team and was noted to be tearful and in low mood.
Later the same day she was fatally struck by a train.
The coroner has now issued a report to try to prevent any similar future deaths.
Ms Murphy, in her report, said: âDuring the course of the investigation my inquiries revealed matters giving rise to concern.
âIn my opinion there is a risk that future deaths could occur unless action is taken.â
The coronerâs report said her concern was the fact that Ms Tetley was removed from the inpatient bed list on June 25, before an attempted review by a mental health practitioner later the same day.
Ms Murphy continued: âI am concerned that there is a risk that patients are removed from the inpatient bed list before an appropriate review that day, by a mental health professional.â
The report, sent on September 14, gives the chief executive of Cheshire and Wirral Partnership NHS Trust, 56 days to respond.
If you are experiencing feelings of distress, or are struggling to cope, you can speak to the Samaritans, in confidence, on 116 123 (UK and ROI), email jo@samaritans.org, or visit the Samaritans website to find details of your nearest branchIf you are based in the USA, and you or someone you know needs mental health assistance right now, call or text 988, or visit 988lifeline.org to access online chat from the 988 Suicide and Crisis Lifeline. This is a free, confidential crisis hotline that is available to everyone 24 hours a day, seven days a week. If you are in another country, you can go to www.befrienders.org to find a helpline near you.
