A Rochdale grooming gang victim who suffered 'significant' sexual abuse took her own life after being removed from hospital, a coroner has concluded.
Charlotte Tetley, 33, saw her mental health spiral after she was taken off an inpatient bed list on June 25 last year, assistant coroner for Cheshire, Sarah Murphy, ruled.
The decision was made before an attempted mental health review by a specialist practitioner later the same day.
She killed herself just months later, on September 24, by sitting on train tracks in the town of Macclesfield, Cheshire, until she was hit.
The young woman had a 'complex longstanding mental health history', her now concluded inquest at Cheshire Coroner's Court in Warrington heard this month.
It came after she was targeted by the child sex trafficking ring in nearby Rochdale, Greater Manchester, which subjected her to 'significant sexual abuse'.
She had been under the Macclesfield Community Mental Health Team since July 2023 when she moved from Rochdale after her abuser returned to the area.
Ms Tetley had been diagnosed with an emotional unstable personality disorder and, previously, post-traumatic stress disorder.
She was also earlier diagnosed with substance misuse, causing behavioural and mood disorder, using drugs as a coping mechanism.
Concerned for her own safety, with thoughts of jumping in front of a train, she went to A&E at Macclesfield Hospital on June 18 last year.
But six days of daily reviews later, doctors decided she did not need a mental health inpatient bed - even though she herself felt it was the only way she could get better.
The next day, Ms Tetley, who was homeless, was discharged before an attempted review by a mental health specialist.
She later engaged with the community mental health team and community drug services and called her family expressing dismay about the situation.
But just months later, on September 18 last year, she was removed from railway tracks by British Transport Police and taken back to A&E at Macclesfield Hospital.
Ms Tetley had reported feeling suicidal to the workers who had found her - but she left the hospital before being reviewed by the mental health liaison team.
Hospital staff called police to report her as a 'high-risk' missing person - but they were told she did not meet the criteria for a search.
The clinicians had asked to speak with a police supervisor after the young woman suddenly left their care.
But they were informed, her inquest heard: 'As Ms Tetley had not voiced [the] intention to end her life, it could not be known that this was her intention when she left the department.'
Ms Murphy said: 'The police maintained that nobody would be deployed and suggested that a response vehicle should go out.
'The ambulance service was duly contacted... but the clinical lead was informed that, as the whereabouts of Ms Tetley was unknown, they would not deploy anyone.'
On the morning of her death, on September 24, she spoke with her mental health key worker and expressed longstanding suicidal ideation without immediate intent.
She also attended the office of the community drug and alcohol team and was noted to be tearful and in low mood - before she was fatally struck later that day.
The young woman had also been set to appear at a court hearing that day, which she did not attend.
The coroner has now issued a prevention of future deaths report to try to stop anything similar happening again.
Ms Murphy 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.'
She highlighted in particular: '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.'
It also noted: 'At the time of her death, she was prescribed medication, but her concordance was sporadic and influenced by whether she had accommodation.
'She had taken multiple previous overdoses with intent to end life.'
The report, sent on September 14, gives the chief executive of Cheshire and Wirral Partnership NHS Trust until November 9 - a total of 56 days - to respond.
Ms Tetley was named as a victim of the Rochdale grooming gang for the first time by the coroner during the inquest.
The sickening child abuse ring saw girls as young as 12 groomed with free booze and drugs before being gang-raped.
Many were expected to have sex 'whenever and wherever' the defendants and other men wanted in filthy flats, cars, car parks, alleyways and disused warehouses.
For confidential support call the Samaritans on 116123 or visit a local Samaritans branch, see www.samaritans.org for details.