A woman with a history of mental health problems took her own life, a coroner has concluded.

An inquest into the death of 28-year Charlotte Metcalfe, who was found dead at her home in Patley Moor Crescent in Darlington, has now been carried out.

Crook Coroners’ Court heard from Home Office pathologist Nigel Cooper, who did a post-mortem examination, found she had taken an overdose of prescribed medication.

The court was told she had struggled with her mental health for ‘most, if not all,’ of her adult life.

While she had not been diagnosed, the inquest heard she displayed symptoms that suggested she suffered from an emotionally unstable personality disorder.

In June, 2022, she went to psychiatric hospital as an inpatient and was detained under the Mental Health Act for part of her eight-day stay there.

The day after she was discharged, she contacted the Tees, Esk and Wear Valley Trust crisis team and returned to hospital.

She was prescribed medication and sent home again to be seen by the home treatment team but the care lasted just two days before she was put into the care of her GP.

On December 2, 2022, her GP tried to make an urgent referral to West Park Hospital in Darlington but the referral was never received.  

Four days later Miss Metcalfe contacted mental health services stating she was ‘deep in crisis’ but, the inquest heard, there was no involvement from the team at that stage.

On January 17, 2023, her GP made a further referral to the mental health team but it was not recorded as received until February 7.

Assistant coroner for County Durham Rebecca Sutton said: “I understand referrals should be actioned the same day this did not happen in Charlotte’s case.

“In accordance with national guidelines an initial needs review should have taken place within four weeks of the referral.

An attempt to call Miss Metcalfe was made on March 25 but she did not answer, and not further attempt was made to contact her by telephone, the inquest heard.

The coroner said: “It was acknowledged by TEWV witnessed that further attempts should have been made to contact Charlotte.”

The trust wrote to Miss Metcalfe asking her to make contact, which she did, and an initial needs review was set up for June 26, 2023.

However, the inquest was told her mental health deteriorated before then and on June 14 she tried to contact the team but was unable to get through so asked her GP to get in touch on her behalf.

She was called back the following day but, on June 21, she tried to take her own life and was hospitalised.

She was allowed to leave but once again attempted to take her own life and was taken to hospital but discharged herself.

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The coroner said: “There were concerns about her and police were contacted.

“The police refused to attend stating it was not a police matter.

“An ambulance attended Charlotte’s home and she refused to return to hospital.”

An urgent mental health appointment was made on Friday, June 23, but Miss Metcalfe did not attend.

The inquest heard TEWV staff did not follow their own procedures for a ‘did not attend’ and there was no attempt to visit her home as there should have been.

No checks were carried out by TEWV over the weekend but on June 26 a social worker called around and was concerned because there was no answer.

Police were called and gave access to the property.

Miss Metcalfe was found dead inside.

The inquest was told she had left a note.

The coroner recorded a verdict of suicide.

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She said: “I have to be sure not only did Charlotte take her own life but, at the time, she intended to take her own life and, on the evidence, I find that both these tests for suicide have been met.

“I would like to express my sincere condolences to her family.”

The Northern Echo is supporting grieving families who have lost loved ones to suicide by calling for a public inquiry into the TEWV mental health trust.

A period of intense scrutiny at TEWV has seen it graded ‘requiring improvement’, a raft of critical inquests into patient deaths, and a prosecution by the Care Quality Commission (CQC).

In the past two years, reports from healthcare watchdogs have flagged problems in the trust that “require improvement”, or areas where services are “inadequate”.

The Northern Echo:

Issues highlighted at the trust range from safeguarding practices and incident reports, to lengthy waitlists and overuse of patient restraint.

Resources to support conversations around suicide can be found at www.samaritans.org/tomorrow

Anyone can contact Samaritans, free, 24/7, on 116 123, email jo@samaritans.org or visit www.samaritans.org