Rachel Stoter (pictured) ad been due to act on the day of her death as birthing partner for her sister, who was having induced labour
A teenager threw herself in front of a lorry while walking eight miles home from hospital after doctors refused to section her, an inquest heard.
Rachel Stoter, 18, was allowed to leave, despite two attempts on her life in the previous 48 hours and claiming voices were telling her ‘to jump in front of traffic’.
She had walked two miles on May 22 when she suddenly leaped in front of a lorry on the A47 dual carriageway at Hopton-on-Sea near Great Yarmouth, Norfolk.
The inquest in Norwich heard how the vulnerable teenager later died from her injuries in the nearby James Paget University Hospital, Gorleston-on-Sea.
Rachel’s mother Michelle Whiting agreed her daughter would not have intended to take her own life.
She said Rachel had been due to act on the day of her death as birthing partner for her sister, who was having induced labour.
Her sister’s baby Katie Rachel was born two days later, and took her middle name from her late aunt.
Rachel was diagnosed with emotionally unstable personality disorder and post traumatic stress disorder, and had self-harmed frequently since the age of 13.
The inquest was told she had 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.
Rachel of Beccles, Suffolk, was moved into supported accommodation at Kirkley Cliff in Lowestoft last March.
But on May 21 she was admitted to the James Paget Hospital after a suicide attempt. She made a further attempt on her life in the hospital’s accident and emergency department, the inquest heard.
A mental health assessment by two psychiatrists and a mental health professional the next day deemed she should not be sectioned under the Mental Health Act.
The assessment team said she had declined offers of transport back to her accommodation.
Rachel’s mother Michelle Whiting, claimed after the inquest that her daughter had been ‘let down by mental health teams’.
She said: ‘If they had detained her she would still be alive today.’
Dr Larry Ayuba, consultant psychiatrist with the Norfolk and Suffolk NHS Foundation Trust (NSFT) who took part in Rachel’s assessment said she was released as ‘her risk had not changed’.
Rachel’s sister’s baby Katie Rachel was born two days later, and took her middle name from her late aunt
He told the hearing: ‘While she was still self harming, hospital admissions had not made any difference.
‘Thoughts of self harm were chronic and on-going 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.’
Dr Ayuba said he had earlier detained Rachel under the Mental Health Act in 2015 at Northgate Hospital in Great Yarmouth.
Alison McWilliams, mental health practitioner with Suffolk County Council, said she had intended to inform the Kirkley Cliff accommodation that Rachel was returning, but did not do so as she 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.’
She added: ‘I felt Rachel had the capacity to make decisions involving her care and any repercussions as a result of that.’
Mental health practitioner Clare Gatward who first met Rachel in December 2015 told the inquest that her risk was at a ‘high but stable level’.
She said: ‘Hospital admission for somebody like Rachel is about containment. 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, described the ‘overall care’ of Rachel as ‘good’.
She insisted that the MHA assessment team had ‘made the right decision’.
Ms Howe added: ‘In hindsight lots of people ask why did we let Rachel leave?
‘There isn’t a provision for private transport. That is going to be taken to the acute services forum to have some discussion.’
Norfolk area coroner Yvonne Blake recorded a narrative verdict, ruling out suicide.
She said: ‘I have no doubt Rachel did the act which caused her death. 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’.
Rachel’s mother Ms Whiting agreed her daughter would not have intended to take her own life.
She said Rachel had been due to act on the day of her death as birthing partner for her sister, who was having induced labour.
Her sister’s baby Katie Rachel was born two days later, and took her middle name from her late aunt.
Ms Whiting said: ‘I do not think she would have killed herself, particularly with her sister about to give birth.
‘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.’
A spokesperson for the Norfolk and Suffolk NHS Foundation Trust said after the hearing: ‘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.’