Rochdale grooming gang victim who endured 'significant' sexual abuse took her own life after hospital removal, coroner rules

A Rochdale grooming gang survivor who endured significant sexual abuse took her own life after she was removed from an inpatient bed list, a coroner ruled.

Charlotte Tetley, 33, had been under the Macclesfield Community Mental Health Team since July 2023 after moving from Rochdale when her abuser returned to the area. The inquest at Cheshire Coroner's Court in Warrington heard that she had a complex mental health history, including an emotional unstable personality disorder and post-traumatic stress disorder, along with substance misuse that affected her behavior and mood.

On June 18 of last year, Tetley went to Macclesfield District General Hospital’s A&E expressing concerns for her safety and thoughts of self-harm. After six days of daily reviews, clinicians concluded she did not need a mental health inpatient bed, even though she believed inpatient support was the only viable route to stability. The following day she was discharged while an outpatient review by a mental health specialist was planned but not completed. She was homeless at the time, and her discharge coincided with ongoing engagement with community services and conversations with her family expressing distress about the situation.

Just months later, on September 18, Tetley was found on railway tracks in Macclesfield and was removed from the location by British Transport Police, then taken back to A&E. She had told workers she felt suicidal, but she left before the mental health liaison team could review her. Police were told she did not meet the criteria for a search as she had not stated an explicit intent to end her life at that moment, a point stressed by the coroner. The following morning she spoke with a mental health key worker and attended meetings with the community drug and alcohol team, appearing tearful and in low mood, before she was fatally struck later that day. She was also due to attend a court hearing that day and did not appear.

A coroner’s prevention of future deaths report was issued, identifying gaps in practice that could put patients at risk. In her ruling, Assistant Coroner for Cheshire Sarah Murphy wrote that the investigation revealed matters giving rise to concern and that there was a real risk that future deaths could occur unless action is taken. In particular, Murphy highlighted the risk that patients can be removed from the inpatient bed list before an appropriate review by a mental health professional on that day. The report also noted that Tetley, at the time of her death, was prescribed medications but had sporadic concordance tied to housing stability. It is noted that she had previously attempted multiple overdoses with intent to end her life.

The coroner’s inquiry also revealed Tetley’s status as a victim of the Rochdale grooming gang, a criminal network that exploited girls as young as 12 through grooming, drugs, and alcohol before gang-raping them. The inquest explicitly named Tetley as a victim of the abuse the group subjected her to, a detail that emerged during the proceedings and was discussed in relation to her long-standing mental health struggles. The coroner’s report was sent to the chief executive of Cheshire and Wirral Partnership NHS Foundation Trust, who was given until November 9 to respond, directing the NHS body to consider systemic changes to prevent similar tragedies in the future.

The case underscores longstanding concerns around the timely assessment and safeguarding of patients who present with severe mental health needs, particularly when housing instability and substance misuse are present. The inquest also highlighted gaps in the process for coordinating hospital discharge with ongoing community support, a factor the coroner said could contribute to worsening risk for individuals in similar circumstances. The authorities have signaled that reforms are needed to ensure that an inpatient bed, when clinically indicated, is not withdrawn before a robust, on-the-spot review by a qualified mental health professional.

Tetley’s death comes as authorities continue to grapple with how best to support survivors of exploitation and ensure that the mental health and social support systems respond promptly to warning signs. The coroner’s decision to issue a prevention of future deaths report aims to prompt decisive, systemic changes and to prevent recurrence of similar outcomes by addressing identified gaps across inpatient bed decisions, ongoing risk assessment, and interagency communication.

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