Vulnerable Suffolk teenager died jumping into traffic on busy road soon after leaving hospital, inquest told
PUBLISHED: 18:13 10 January 2018 | UPDATED: 18:13 10 January 2018
An 18-year-old from Suffolk who jumped in front of traffic on a busy road after being released from hospital received good care, an inquest heard.
Rachel Stoter, 18, had been allowed to walk the eight miles home to Lowestoft after undergoing a Mental Health Assessment on May 22 last year decided she should not be detained, area coroner Yvonne Blake told Norfolk Coroner’s Court today.
This was despite two attempts on her own life in the 48 hours leading up to her death. Diagnosed with emotionally unstable personality disorder and post-traumatic stress disorder, Rachel had self harmed frequently since she was 13.
Making multiple attempts on her own life, which her mother called “cries for help”, she had spent her teenage years in various mental health facilities.
She was admitted to the James Paget Hospital (JPH) on May 21 last year after a suicide attempt, and made a further attempt while in A&E.
The next day, after two psychiatrists and a mental health professional deemed she could not be sectioned, she jumped into the path of a lorry on the A47 in Hopton while walking home to Kirkley Cliff in Lowestoft.
The 18-year-old had been due to act as a birthing partner for her sister later that day.
Katie Rachel was born two days later, taking her middle name from her late aunt. Rachel’s mother, Michelle Whiting, said her daughter had been let down by mental health teams after the inquest.
She said: “If they had detained her, she would still be alive today.”
Catherine Howe, author of the Serious Incident Requiring Investigation (SIRI) report carried out at the Norfolk and Suffolk NHS Foundation Trust (NSFT), said “overall [Rachel’s] care was good” and the MHA assessment team made the right decision to not detain Rachel.
She told the inquest: “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.”
Area coroner Yvonne Blake gave a narrative verdict.
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.”
Ms Whiting agreed her daughter would not have intended to take her own life. She added: “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.”
The Samaritans are available to talk 24/7 on 116 123.
“Loss of life should never happen”
An NSFT spokesman 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.”