The suicide of a woman on a railway line, who had doused herself in petrol weeks before her death, has prompted a review of mental health services, an inquest heard yesterday.

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Margaret Griffiths was killed on May 27 last year when she was hit by the 17.45 Norwich to Sheringham service at around 6pm at Salhouse station.

The 54-year-old, who had a history of mental health and alcohol problems, first saw a mental health nurse at Hellesdon hospital almost four months earlier at the start of February. She was also helped by the wellbeing service at the hospital.

Mrs Griffiths’ death prompted an investigation by the Norfolk and Suffolk NHS Foundation Trust.

Its report found information and notes about Mrs Griffiths should have been shared better and staff could have responded to her condition differently.

Coroner William Armstrong said: “There were omissions in accessing information, sharing information and in formulating an appropriate response.”

But Mr Armstrong said he had been “heartened” by the changes the trust had made since Mrs Griffiths’ death, which include one point of contact for incoming patients and sharing notes about patients between different departments.

In a statement read at the inquest the train’s driver recalled how he slammed on his emergency brakes when he saw Mrs Griffiths and her two dogs on the track.

He sounded his horn and gestured at her to move out the way, but she shook her head and looked back at him, the inquest heard.

Mrs Griffiths, who lived in Rackheath, was around two times over the drink drive limit when she was struck.

The train could not stop in time and she was taken to the Norfolk and Norwich University Hospital (NNUH) where she was pronounced dead.

The secretary had expressed suicidal tendencies through notes stating “the railway is calling” which a neighbour saw. After her death a carrier bag full of notes was found with apologies to different people.

On May 6 Mrs Griffiths had been taken to the NNUH after dousing herself in petrol. And on May 3 neighbours had found her wandering the street in her night gown.

Weeks before her death health workers believed her condition had been improving, but Mrs Griffiths appears to have started drinking again after splitting up with her partner. She was then arrested and fined for harassing him.

Anyone needing someone to talk to can contact the Samaritans on 0845 790 9090.

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