An inquest has ruled that a woman who was groomed and sexually abused in Rochdale took her own life.
Charlotte Tetley 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.
Her inquest at Cheshire Coroner’s Court in Warrington heard the 33-year-old had a complex longstanding mental health history and was a victim of the grooming in Rochdale, suffering, "significant sexual abuse."
Now, the coroner has issued a report to try to prevent any similar future deaths.
Her inquest heard Ms Tetley had been under the Macclesfield Community Mental Health Team since July 2023 when she moved from Rochdale after her abuser returned to the area.
She 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.
Charlotte Tetley died in Macclesfield last year
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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 District General Hospital.
Ms Tetley 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.
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Ms Tetley checked in to Macclesfield District General Hospital
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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 near Macclesfield.
South Cheshire coroner Sarah Murphy said: "The police maintained that nobody would be deployed and suggested that a response vehicle should go out.
"The ambulance service was duly contacted...but the clinical lead was informed that, as the whereabouts of Ms Tetley was unknown, they would not deploy anyone".
Ms Murphy, in her report released to the public today, said: "During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken."
The coroner’s 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.
The Coroner continued: "I 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."
The report, sent on September 14, gives the chief executive of Cheshire and Wirral Partnership NHS Trust 56 days to issue an official response.
The Coroners' Court in Warrington, Cheshire where her inquest was held
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In January 2024, a review revealed girls in Rochdale were "left at the mercy" of paedophile grooming gangs for years because of failings by senior police and council bosses.
The review focused on 111 cases in the town from 2004 to 2013 and set out a series of failed investigations by Greater Manchester Police.
Rochdale Council said it was "determined to ensure these terrible failures do not happen again".
Anyone who is in emotional distress, struggling to cope or at risk of suicide can call the Samaritans anonymously for free from a UK phone on 116 123 or go to samaritans.org.