Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0466, written 14 Sep 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Sep 2025 |
|---|---|
| Reference | 2025-0466 |
| Deceased | Charlotte Tetley |
| Coroner | Sarah Murphy |
| Coroner area | Cheshire |
| Category | Suicide (from 2015) |
| Organisation named | Cheshire and Wirral Partnership NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Chief Executive of Cheshire and Wirral Partnership NHS Trust 1 CORONER I am Sarah Murphy, assistant coroner for the coroner area of Cheshire. 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 30 September 2024 I commenced an investigation into the death of Charlotte Tetley aged 33. The investigation concluded at the end of the inquest on 5 September 2025. The conclusion of the inquest was that: Death was due to being struck by a train having deliberately sat on the tracks with an intention to end life. She had suffered a deterioration in mental health following a decision to remove her from the inpatient bed list on the 25 June 2024, and subsequent accommodation difficulties. 4 CIRCUMSTANCES OF THE DEATH On the 24 September 2024, Charlotte Tetley was hit by a train travelling though Macclesfield after she had been sat on tracks. There was no easy access to the tracks at this point. Ms Tetley had a complex longstanding mental health history and was a victim of the Rochdale Grooming where she suffered significant sexual abuse. She was diagnosed with Emotional Unstable Personality Disorder and had previously been diagnosed with Post Traumatic Stress Disorder and substance misuse causing behavioural and mood disorder. Drug dependence was a coping mechanism. 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. 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. On the 18 June 2024, Ms Tetley attended the Accident and Emergency Department at Macclesfield Hospital voicing concerns for her safety and thoughts to jump in front of a train. An informal admission was found to be clinically indicated to commence depot injection and to maintain safety. She was reviewed daily until the 24 June where on each day, the clinical records document that an informal admission was necessary. The minutes of the bed management meeting on the 24 June recorded that the Home Treatment Team did not think that Charlotte required a mental health inpatient bed but that the homeless pathway needed to be explored before taking off the inpatient list. This was not recorded in Ms Tetley’s clinical records for the 24 June 2024. The clinical records for the review on the 24 June 2024, document that Ms Tetley felt that the only option for her to get better was for admission. On the 25 June, Ms Tetley was discharged from the inpatient bed list by the bed management team at 10:37 hours. This was before an attempted review by a Mental Health Practitioner at Regulation 28 – After Inquest Document Template Updated 30/07/2021 11:30 hours who did not complete a review due to finding Ms Tetley asleep. A handover had been obtained from Accident and Emergency nursing staff who reported no concerns or change in presentation. It was concluded that Ms Tetley did not appear to require a mental health inpatient admission but might benefit from an admission to a medical ward to address homelessness. It was documented in the clinical records that she was amenable to a discharge. Charlotte left the department at 12:57 hours. It was documented in the clinical records on the 25 June that after discharge, she called her probation officer and was noted to be “screaming” down the phone stating that she was going to the railway line to kill herself. She had also phoned her family expressing dismay about the discharge from the inpatient bed list. The community Consultant Psychiatrist and other mental health practitioners had concerns about the safety of the discharge on the 25 June 2025 which were documented in the clinical records. Ms Tetley’s whereabouts were unknown to the community mental health team until the 2 July when they were contacted by her probation officer. On the 3 July, Ms Tetely received a psychiatric review by a Specialist Registrar, and it concluded that there was no clinical indication for a mental health act assessment or informal admission. Ms Tetley subsequently engaged with the community mental health team and community drug services, but on the 18 September 2024, she was removed from railway tracks by British Transport Police and taken to the Accident and Emergency Department of Macclesfield Hospital. She had reported feeling suicidal to workers who had found her, but she left the hospital before being reviewed by the Mental Health Liaison Team. The police were contacted by the Accident and Emergency Department to report Ms Tetley as a high-risk missing person, but they were informed that under the “Right Place Right Person” policy, nobody would be deployed. The Liaison Psychiatry Clinical Lead requested for this to be escalated to a supervisor and duly spoke with a supervisor. She expressed concerns about an immediate risk to safety for Ms Tetley but was informed that as Ms Tetley had not voiced intention to end her life, it could not be known that this was her intention when she left the department. It was explained by the Liaison Psychiatry Clinical Lead that the fact that Charlotte was not engaging had concerned her more about her immediate safety. The Police maintained that nobody would be deployed and suggested that response vehicle should go out. The ambulance service was duly contacted to request a response vehicle, but the Clinical Lead was informed that as the whereabouts of Ms Tetley was unknown, they would not deploy anyone. Ms Tetley’s keyworker was able to contact her by telephone on the 18 September and arranged to see her the following day. She was reviewed by her keyworker on the 19 September where Ms Tetley requested that an outpatient appointment with her psychiatrist was re-arranged from the 24 September as she had a court hearing that day. On the morning of the 24 September, Ms Tetley did not attend the court hearing and spoke by phone with her mental health keyworker and expressed longstanding suicidal ideation without immediate intent. She attended the office of the community drug and alcohol team and was noted to be tearful and in low mood. She was later fatally struck by a train when she deliberately sat on the tracks. 5 CORONER’S CONCERNS 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. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) That Ms Tetley was removed from the inpatient bed list on the 25 June at 10:37 hours before an attempted review by a mental health practitioner at 11:30 hours the same day. Following daily documented reviews between the 18 June 2024 to the 24 June 2024, it was documented that Ms Tetley required inpatient admission and daily reviews. Regulation 28 – After Inquest Document Template Updated 30/07/2021 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. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 9 November 2025 I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons The family of Charlotte Tetley I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. 9 Dated: 14.9.25 Regulation 28 – After Inquest Document Template Updated 30/07/2021
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Private & Confidential Sarah Murphy (Area Coroner for Cheshire) Cheshire Coroner’s Service Museum Street Warrington Cheshire WA1 1JX Trust Headquarters Redesmere Countess of Chester Health Park Liverpool Road Chester CH2 1BQ Date: 3 November 2025 Dear Madam, We write in response to the Regulation 28 sent to the Chief Executive CORONER’S CONCERNS 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. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: That Ms Tetley was removed from the inpatient bed list on the 25 June at 10:37 hours before an attempted review by a mental health practitioner at 11:30 hours the same day. Following daily documented reviews between the 18 June 2024 to the 24 June 2024, it was documented that Ms Tetley required inpatient admission and daily reviews. 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. Trust Findings The Trust has conducted an internal review into the care of Ms Tetley, focusing on the period between 18 June – 25 June 2024 and subsequent follow-up. It outlines what happened, where processes failed, and what organisational learning has been identified across four key domains: 1. Record keeping and communication. 2. Assessment and admission decisions 3. Clinical governance and escalation 4. Learning and system improvement On the 18th of June 2024 Ms Tetley presented to the Accident and Emergency Department (AED) with active suicidal ideation (intention to jump in front of a train). She was awaiting an informal admission for safety and initiation of depot medication. Daily reviews by First Response continued until 24 June 2024. Ms Tetley also had a Consultant and Key Worker in the community. On the 25 of June 2024 the Trust held a Clinical Prioritisation Meeting. At this meeting there was a Multidisciplinary Team (MDT) decision made to remove Ms Tetley from inpatient bed list, the rationale was she was viewed as requiring support for her homelessness status rather than having an acute mental illness that required inpatient admission. Ms Tetley’s consultant (Dr Singh) and Community keyworker were not involved in the decision; however, they had the opportunity to attend the meeting. They raised concerns about the safety of Ms Tetley not being admitted on the 25 June 2024 after she had left AED, their concerns including her vulnerability as she was homeless, she did not have any medication and there was no safety plan in place. These concerns were raised with the Operational lead from First Response who stood by the MDT decision that admission to an acute inpatient bed was not required. On review the MDT decision was not documented within Ms Tetley’s clinical record (breach of CP3 Health Records Policy). The Clinical Prioritisation Meeting is held daily and all patients who are waiting for admissions to a mental health inpatient bed are discussed and prioritised based on their clinical needs. The meeting was chaired by a Senior Clinical Lead from the First Response service, with Home Treatment (HTT) and Liaison Psychiatry leads, medical support, Patient Flow Team in attendance. This meeting supports the allocation of inpatient beds based on the severity of clinical presentation, safety concerns, and the appropriateness of admission. The reviews that are completed within the meeting are patient-centred and risk-informed, ensuring that decisions are guided by the person’s individual need. During the Clinical Prioritisation Meeting on 25 June 2024, there was difference between Ms Tetley’s clinical records and the meeting minutes. Ms Tetley’s clinical record stated that she believed that an admission was her only viable path to recovery, whereas the minutes from the Clinical Prioritisation Meeting stated that the Home Treatment Team did not consider that an inpatient admission was indicated for Ms Tetley and recommended exploring the homeless pathway prior to removing her from the inpatient list. Ms Tetley’s wishes to be admitted do not seem to have been considered or discussed at the meeting. During the Clinical Prioritisation Meeting, a discussion took place between the First Response staff regarding Ms Tetley’s current presentation and care needs. Following clinical review and consensus among all attendees, it was agreed that she would be removed from the inpatient bed list. The decision was based on the assessment that Ms Tetley’s primary need at that time related to accommodation rather than acute mental health admission, and that her care would be better supported through appropriate housing interventions. Ms Tetley was removed from the bed list before a further clinical review by the Mental Health Practitioner: this was planned for the 25 June 2024. The Mental Health Practitioner attended A&E on the 25 June 2024 but did not assess Ms Tetley directly (she was asleep). The decision not to admit was based on previous daily reviews and A&E staff feedback. On review there is individual learning for the member of staff, and this is being addressed via supervision Ms Tetley later learned of the decision not to admit, became highly distressed, and expressed renewed suicidal intent to her Probation Officer. Ms Tetley’s keyworker, Consultant and Probation Officer had raised urgent safety concerns. The concerns by the Key worker and Consultant were raised to the Operational Lead for First Response who stood by the decision made at the Clinical Prioritisation Meeting. On review the Trust has identified learning around the escalation of clinical differences which is detailed further below, Following Ms Tetley leaving the AED on 25 June 2024, her community Keyworker, and the Home Treatment Team (HTT) tried to contact her via phone, initially voice messages were left as the calls went direct to her answer phone. Contact was made with Ms Tetley by her Community Keyworker on the 3rd of July 2024, following this there were a further six appointments with her Community Keyworker as well as three telephone contacts, on one occasion Ms Tetley attended AED. It was difficult to remain in contact with Ms Tetley as she moved accommodation three times during this period. On each visit a full Mental Health Assessment was completed, noting admission to a psychiatric inpatient unit was not indicated. A full 5 P Risk formulation was completed on the 19 September 2024 by Ms Tetley’s Community keyworker. A 5 P Risk Formulation is a structured framework used in mental health to understand and manage an individual's psychological difficulties and potential risks; it helps clinicians build a comprehensive formulation by exploring five key areas. This was the last contact with Ms Tetley before her tragic death. Key Findings and Learning Points 1. Record Keeping and Communication • Differences between clinical records and the Clinical Prioritisation Meeting minutes. Ms Tetley’s wishes to be admitted do not seem to have been considered or discussed at the meeting • The Clinical Prioritisation Meeting Multidisciplinary Team (MDT) decision was not recorded within Ms Tetley’s Clinical Records (SystmOne), this is a breach of the Record Keeping policy. • Fragmented communication across teams First Response, Home Treatment Team, Liaison Psychiatry, Community Mental Health Team • Learning and actions o All clinical decisions must be contemporaneously recorded in the patient’s record. o Clinical notes must align with multidisciplinary discussions made in meetings. o Administrative support has now been added to ensure meeting outcomes are entered into SystmOne. o Safety messages (“Safety Soundbites”) have been shared with staff highlighting the fragmented communication between the teams and importance of aligning clinical notes with multidisciplinary decisions. A safety soundbite is a brief, focused statement used to highlight a key safety concern and associated actions and ensures that important safety information is communicated clearly and efficiently across the Trust. 2. Assessment and Admission Decisions • The decision to remove Ms Tetley from the bed list was made on 25th June, 2024 however prior to her leaving AED there was no assessment completed on 25th June as she was sleeping and did not receive a daily review: this is not in line with clinical safety standards. The Mental Health Practitioner relied on indirect information (A&E staff handover) and previous daily assessment completed by First Response staff instead of completing an assessment. • Missed opportunity to review Ms Tetley, communicate compassionately with her and review her. • Learning: o Patients awaiting admission must receive a daily face-to-face clinical review before any removal from the bed list. o Practitioners must complete assessments even if the patient is asleep (return later if necessary). o Decision-making should always be informed by updated clinical evaluation and patient engagement. o All teams who are directly involved with the patient must be involved in decisions and their care, so care is delivered safely, and patients have what they need e.g. a safety plan and medications. 3. Escalation and Governance Ms Tetley’s Consultant admit but were unaware of the decision until after she left A&E and her keyworker disagreed with the decision not to • No clear process existed for discussing care or escalating clinical differences of opinion. • Learning: o A new Standard Operating Procedure (SOP) – Escalation Process for Clinical Differences of Opinion – Mental Health Bed List – has been developed and is under peer review. This ensures clinical disagreements are escalated to Clinical Directors promptly. o A Patient Flow Meeting now follows the Clinical Prioritisation Meeting to ensure decisions are discussed and communicated across all teams. This meeting focuses on the admissions and discharge planning for all inpatients across CWP. 4. Compassionate Communication and Patient Engagement • Ms Tetley was not informed of the decision regarding her care in a compassionate or supportive way. This omission caused significant distress and upset to Ms Tetley • Learning: o Clinical reviews must include direct, compassionate communication with patients. o Decisions affecting safety and wellbeing must be explained clearly to the patient and care team. System Changes Implemented • • • • • • Outcomes of Clinical Prioritisation Meetings are now directly documented in SystmOne. Administrative support embedded within First Response to ensure record accuracy. Establishment of the Patient Flow Meeting to ensure consistent communication across services and all teams. Introduction of an open invitation for all clinicians to attend the Clinical Prioritisation Meeting to provide key clinical history and information to inform decision making for patients. Development of the SOP for Escalation of Clinical Differences. Reflective supervision undertaken with the Mental Health Practitioner involved. Reinforcement of training around record keeping, communication, and risk-informed decision-making. The care provided to Ms Tetley did not meet expected standards. There were lapses in assessment, communication, documentation, and compassionate care. The Trust acknowledges the distress this caused Ms Tetley, and we are deeply sorry for this. There is significant learning for the Trust, and we have taken steps to ensure we deliver high quality care to others and reduce the risk of this happening to other patients. The Trust will be issuing a formal apology to Ms Tetley’s family and acknowledge the harm caused. Yours faithfully Chief Executive Cheshire and Wirral Partnership NHS Foundation Trust
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