Fiona Gale, 29A young woman suffering mental illness took her own life just hours after being discharged from a psychiatric hospital, an inquest heard.

Fiona Gale, 29, from Sherston, was killed by a train on the evening of March 2 last year at Alderton Bridge following her discharge from the Green Lane Hospital, in Devizes, that same afternoon because staff were unhappy with her behaviour.

An eight-strong jury at Trowbridge Town Hall this week agreed Miss Gale took her life while her mind was unbalanced but their unusual narrative verdict concluded her threats to kill herself were not taken seriously enough.

"We are satisfied that Fiona was discharged by medical staff and would have recognised this as more than home leave," the jury said.

"Fiona had stated repeatedly and to a number of people her intention to kill herself, even down to the manner in which she would accomplish this act.

"We feel that the threat of ending her own life was not taken as a serious risk that required immediate action to prevent ie hospitalisation."

The jury heard shocking evidence that voluntary patients indulged in drink and drugs, had access to razor blades and even had sex.

This type of behaviour resulted in staff telling Miss Gale she had to leave. Different witnesses presented differing versions of whether she was going on home leave in which case she would return or if she was being discharged. But Miss Gale was distraught and said she would jump in front of a train because she couldn't survive at home.

The inquest heard that Miss Gale, a keen horsewoman, suffered severe sexual abuse when she was just eight years old, while her family were living in the USA. Later in her teens she was raped.

In 2001 she developed mental health problems and was diagnosed as suffering borderline personality disorder a consequence of the terrible ordeals she had endured earlier in her life.

Miss Gale's GP Dr John Hancock, from Telsey Surgery, in Sherston, told the inquest she was the most severe asthmatic he had ever cared for and she had two life threatening attacks.

But her mental health problems did not surface until later on.

"Unfortunately from the year 2001 she began to get a very low opinion of herself and around 2001/2002 she started harming herself, usually cutting her arms with a knife or razor blade," Dr Hancock said.

He said that in the last year of her life Miss Gale had threatened to kill herself on many occasions and he was very concerned she would do so.

Miss Gale was admitted to Green Lane Hospital in February 2004 following a serious episode of self harming which the doctor described as the worst he had seen in his medical career.

But during her stay the self harming continued, her drink problem worsened, and she had sex with a male patient who was also on the ward.

Dr David Stevens, consultant psychiatrist at Green Lane Hospital, consulted with the mental health care team and decided she would have to go home.

He told the inquest he wanted this to be a period of home leave, but Miss Gale opted for discharge a fact disputed by her mother, Barbara Gale, and Miss Gale's friend and fellow patient Jane Johnson, who believed she was being thrown out.

Dr Stevens said: "It is one of the most difficult decisions to have to make.

"Is that threat one that one takes seriously or one born out of the condition which she undoubtedly had?

"Can one balance the difficulties she had caused on the ward, with her needs, and the needs of other patients, and can one come to a decision which is just, right, in her interest and the interest of others? I have agonised over that for 12 months."

The mental health team explained her care would continue at home, and would include visits from staff.

Dr Stevens was questioned about the presence of drink and drugs on the ward and he explained the ward was open and patients were allowed to come and go as they wished. They are not searched and the relationship between staff and patients was based on trust.

Ms Johnson told the inquest Miss Gale was very distressed when she was told she would have to leave.

"She said she felt she could not and would not be able to cope at home and if she had to go home she would kill herself," Ms Johnson said.

That day Miss Gale made two telephone calls to her mother, who was at work in Swindon. Mrs Gale said her daughter was hysterical and said they were throwing her out.

Mrs Gale spoke to Dr Stevens: "I remember him saying they were sending her home. I expressed misgivings and Dr Stevens said she had burned her bridges on the ward and I remember thinking what am I going to do?"

Miss Gale left the hospital at about 5pm and at 7.15pm, mother and daughter had a takeaway meal together.

"It's my belief that she made up her mind to kill herself when they abandoned her. The meal was her way of saying goodbye," said Mrs Gale.

The following day, Miss Gale was found dead on the railway line.

Wiltshire coroner David Masters advised the jury they could record a verdict of suicide or an open verdict. He directed a finding of neglect was not justified but explained a narrative verdict gave room to add comments about the manner of her death.

At the end of the inquest, Mr Masters said he would support the mental health trust in its application for a crisis house, to serve as an alternative venue for vulnerable people who needed a supportive environment.

System 'let down my daughter'

Fiona Gale's mother Barbara has laid the blame for her daughter's suicide firmly at the door of the mental health services and says they sent her home to die.

Now the inquest is over, Mrs Gale is intending to meet with the Wiltshire and Avon Mental Health Trust in a bid to prevent such a catastrophe ever happening again.

But she has no intention of suing the trust and will not launch a crusade. "She would not have wanted me to go on a crusade," said Mrs Gale.

She said no amount of money would bring her daughter back and added the trust was already under-funded and needed every penny it had.

"When Fiona was well she was everything anyone could have wanted in a daughter. She was loving and vivacious," said Mrs Gale. "When she was ill she was a different person. It was hard for all of us to manage, but we all tried, because we loved her."

Mrs Gale believes it was the healthcare system that let her daughter down rather than any individual.

When Miss Gale's behaviour was reckoned hard to deal with on the ward, there was nowhere else appropriate to send her.

"They sent her home to die," said Mrs Gale. "They sent her home because they could not cope. There was nowhere else for her to go."

Mrs Gale said mental healthcare was the Cinderella service and blamed a chronic lack of resources.

"At one time there were 2,500 beds for mental health patients in Wiltshire now there are only 63.

"It is not enough. There are not enough beds, or staff, or psychiatrists, and a lot of the staff are not well enough trained to deal with difficult patients."

Dr Caroline Vize, consultant psychiatrist and director of clinical practice at the mental health trust, expressed its condolences to Miss Gale's family and friends.

"Fiona was a lady with complex mental health needs whom trust staff worked hard to support, but despite tremendous efforts, this tragic event occurred," she said. "Everyone who worked with Fiona was shocked and saddened by her death."

Dr Vize added: "The trust audits all unexpected deaths as part of its programme of continually reviewing and learning from both adverse and good outcomes in order to provide the highest standard of clinical care. We were disappointed with some aspects of the outcome and process of the inquest, but we will be reflecting seriously on the verdict and the comments that have been made."