Concerns raised by coroner after inquest finds Rochdale grooming gang victim took her own life
A Rochdale grooming gang victim took her own life, an inquest has heard.
Charlotte Tetley was just 33-years-old when she died after being struck by a train at Macclesfield station on September 24, 2024.
At an inquest earlier this month, it was heard how Ms Tetley had a 'complex longstanding meatal health history' and was a victim of the child sex abuse ring in Rochdale, suffering 'significant sexual abuse'.
Assistant coroner for Cheshire, Sarah Murphy, noted that Ms Tetley's mental health deteriorated following a decision to remove her from the inpatient bed list in June 2024, along with subsequent accommodation difficulties.
Following the inquest, Ms Murphy produced a prevention of future deaths report, outlining her concerns about the care Ms Tetley received.
She wrote: "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. In the circumstances it is my statutory duty to report to you.
"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."
Ms Tetley was diagnosed with emotionally unstable personality disorder and had previously been diagnosed with post-traumatic stress disorder and substance misuse causing behavioural and mood disorder.
The inquest record states that drug dependence had become a 'coping mechanism'.
Ms Tetley had been under the Macclesfield Community Health Team since July 2023, having moved from Rotherham after her abuser returned to the area.
On June 18, 2024, she attended A&E at Macclesfield Hospital, voicing concerns for her safety.
On June 25, she was discharged by the bed management team after it was determined that she did not appear to require a mental health inpatient admission.
It was documented in the clinical records that upon being discharged, Ms Tetley called her probation officer, stating that she was going to kill herself.
She also phoned her family expressing 'dismay' about being discharged.
Concerns about the safety of the discharge were also raised by the community consultant psychiatrist and other mental health practitioners.
On September 18, Ms Tetley was removed from the railway tracks by British Transport Police and taken to A&E.
She had reported feeling suicidal to the workers who had found her but left the hospital before being reviewed by the mental health liaison team.
In a separate prevention of future deaths report, Ms murphy raised concerns about the police response in regards to a high risk missing person.
She wrote: "If the policy is interpreted such that police resources will only be deployed if the missing person has expressed an intention to end life as they leave the hospital, there is a risk that future deaths will occur.
"It is unlikely that the ambulance response vehicle will be deployed if the whereabouts of the missing person is unknown, which will result in the missing person not being able to receive medical attention until their whereabouts are known.
"By the time that they are located, there is a risk that they will no longer be alive."
On September 19, Ms Tetley spoke with her mental health keyworker and requested to re-arrange an outpatient appointment with her psychiatrist as she had a court hearing.
She did not attend the court hearing, calling her keyworker and expressing 'longstanding suicidal ideation without immediate intent'.
She then attended the office of the community drug and alcohol team and was noted to be 'tearful and in low mood'
Later that same day, Ms Tetley was fatally struck by a train.
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