A review into the death of a vulnerable 18 year-old who jumped into traffic on the A47 after being released from the James Paget Hospital found she received 'good care', an inquest has heard.
Rachel Stoter had been allowed to walk the eight miles home to Lowestoft after a mental health assessment on May 22, 2017 found she should not be detained, despite two attempts on her own life in the previous 48 hours.
Diagnosed with emotionally unstable personality disorder and post-traumatic stress disorder, Rachel, from Beccles, had self harmed frequently since the age of 13.
She made multiple attempts on her own life, which her mother called 'cries for help', and spent much of her teenage years in various mental health facilities.
In March 2017 she moved into supported accommodation at Kirkley Cliff in Lowestoft and by May 21 she was admitted to the James Paget Hospital (JPH) after a suicide attempt. While at A&E she made a further attempt on her life.
The next day, after two psychiatrists and a mental health professional deemed she could not be sectioned under the Mental Health Act, Rachel jumped into the path of a lorry on the A47 at Hopton.
Later that day she had been due to act as birthing partner for her sister, who was having induced labour. Katie Rachel was born two days later, and is now seven months old, taking her middle name from her late aunt.
After the inquest into her death Rachel's mum, Michelle Whiting, said her daughter had been 'let down by mental health teams'.
'If they had detained her she would still be alive today,' she said.
Norfolk Coroner's Court heard from the assessment team who discharged her from hospital after she had declined offers of transport.
Dr Larry Ayuba, consultant psychiatrist with the Norfolk and Suffolk NHS Foundation trust (NSFT), had detained Rachel under the Mental Health Act (MHA) in 2015 at Northgate Hospital in Great Yarmouth.
When he saw Rachel again at JPH on May 22, 2017 he said 'her risk had not changed' and she was released to return to supported accommodation.
'While she was still self harming, hospital admissions had not made any difference,' he said.
'Thoughts of self harm were chronic and ongoing and it appeared the risk had been quite consistent. Our decision hinged on the fact she already had a very good care package in the community and she was willing to continue to engage.
'It is a known fact for people who suffer from emotionally unstable personality disorder, admissions into hospital actually make things worse.
'If for any reason we had any doubts in our minds at that time we would have gone ahead and detained her.'
Alison McWilliams, mental health practitioner with Suffolk County Council, attended JPH after Norfolk were unable to provide doctors for the MHA assessment.
She had intended to inform Kirkley Cliff Rachel was returning home from JPH but soon had three urgent referrals to deal with.
In the assessment she said Rachel had 'presented as a sad, emotionally damaged young woman rather than someone with an acute mental disorder in need of hospital admission.
'I felt Rachel had the capacity to make decisions involving her care and any repercussions as a result of that,' she said.
Mental health practitioner Clare Gatward first met Rachel in December 2015 and told the inquest her risk was at a 'high but stable level'.
'Hospital admission for somebody like Rachel is about containment,' she said. 'It is an option for a short period of time to manage the risk.
'She had said voices were telling her to jump in front of traffic but she offered reassurance she would keep herself safe.'
Catherine Howe, author of the NSFT Serious Incident Requiring Investigation (SIRI) report, said 'overall [Rachel's] care was good' and the MHA assessment team 'made the right decision'.
'In hindsight lots of people ask why did we let Rachel leave?' she said. 'There isn't a provision for private transport. That is going to be taken to the acute services forum to have some discussion.'
Area coroner Yvonne Blake recorded a narrative verdict, ruling out suicide.
'I have no doubt Rachel did the act which caused her death,' she said. 'She was known to be very impulsive. She had harmed herself numerous times without apparent intention to end her own life.
'She stepped out in front of traffic but there is no evidence she fully understood the consequences of that action'.
Ms Whiting agreed her daughter would not have intended to take her own life.
'I do not think she would have killed herself, particularly with her sister about to give birth,' she said.
'I just feel there should have been more support. It is seven or eight miles to Lowestoft and they should never have released her without something being in place.
'She was beautiful inside and out and we will miss her forever.'
The Samaritans are available to talk 24/7 on 116 123.
'Loss of life should never happen'
A spokesperson for the Norfolk and Suffolk NHS Foundation Trust said: 'We offer our sincere condolences to all those affected by Rachel's tragic and shocking death.
'We have met with Rachel's family and will be happy to meet with them further should they wish to do so.
'NSFT provided Rachel with care and treatment appropriate to her needs and in accordance with her wishes for a number of years, and the clinicians who supported her have also been deeply saddened by her death.
'Even when our care is not in question, as in this case, at NSFT we treat every loss of life as an event that should never happen to ensure we take any learnings. As such we have undertaken a thorough investigation into the care provided and this has resulted in recommendations to improve current practice.
'These have included arranging multi-agency review meetings where service users are under the care of numerous agencies, and improving the design of some of our clinical records so that relevant clinical information can be added more efficiently.'
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