Overview

• Assistant coroner Sarah Murphy concluded the 33-year-old, a Rochdale grooming victim, took her own life in Macclesfield in September 2024.
• The coroner identified a systemic risk of patients being removed from an inpatient bed list before an appropriate same-day review by a mental health professional.
• Tetley was taken off the bed list on June 25, 2024, days after attending A&E with suicidal thoughts, and her mental health then deteriorated.
• Evidence described missed crisis-care opportunities, including her leaving A&E before a liaison review on 18 September and questions over police and ambulance deployment when her whereabouts were unknown.
• The report was sent on 14 September to the Cheshire and Wirral Partnership NHS Trust, which must propose actions to reduce the risk of similar deaths.