A coroner has criticised a national health service care system as “bonkers”, saying it let down a vulnerable and suicidal young mother who went on to kill herself.

An inquest heard that Rebecca Kelsall, 31, had sought counselling for depression but did not receive adequate care and later took her own life. The coroner John Pollard said that rules within Britain’s mental healthcare regime had left Kelsall stranded without regular professional help.

The inquest in Stockport, heard that Kelsall, who had two children, killed herself after NHS rules stopped health workers asking if she was ill, even though she had already told doctors she had been suicidal. Pollard described the rules as “bonkers”, adding that it was a NHS care system worthy of a “world in Alice in Wonderland”.

In May 2015, Kelsall phoned a mental health clinic where she had received counselling to say she was too unwell to make an appointment. Later the same day Kelsall drank vodka and took antidepressants before hanging herself at her home in Stretford, Greater Manchester.

During the inquest into her death it was revealed that Kelsall had sought help from an online therapist saying she was having suicidal thoughts. But she was told she would have to wait four weeks for a face-to-face meeting and in the interim she would no longer be able to seek help online.

She eventually saw a psychologist and again said she had suicidal thoughts. She missed a subsequent consultation due to illness but staff were unable to ascertain the nature of her illness due to “policy” banning “personal questions”.

After missing a further appointment Kelsall was dismissed from the health service and no effort was made to check on her welfare, the coroner heard. It emerged that Kelsall was already dead when she was formally discharged for being absent at the second meeting.

At the inquest Pollard condemned the healthcare system which treated her, saying it was “flawed and poor”, and that she was a vulnerable person who should never have been discharged.

Pollard said: “I believe that the fact somebody has already died and therefore cannot possibly attend their appointment is a pretty exceptional circumstance. This is very poor policy. This system has let her down. Here we have a vulnerable person with a history of problems, and because she doesn’t turn up the system simply says ‘discharge her’. There was no concern that a woman with problems and a history of suicidal thoughts didn’t attend. This seems to me to be a very flawed system.

“I can’t understand why she was not asked why she was feeling unwell. If I rang the bank to say I wouldn’t be going in that day, I wouldn’t expect them to quiz me about it. But if I rang my doctor surgery, who should be solely concerned with my health, to tell them the same thing, I would expect them to ask me why I was poorly.”

Pollard said he would be writing to NHS employers and the Care Quality Commission to express concern about Kelsall’s treatment. “I can feel myself slipping into the world of Alice in Wonderland here. This is a bonkers system. I shouldn’t have to use words like bonkers but I feel it’s appropriate here. People like Rebecca need a system they can rely on. She could have easily remained on the e-therapy system while waiting for cognitive behavioural therapy, and the only reason she didn’t is because the rules wouldn’t let her. This is something I am very concerned about and hope it will be addressed.’’

Kelsall sought professional help under the online system in September 2014. Rachel Jagger, a self-help coordinator for the website, said Kelsall said she was having suicidal thoughts once or twice week. “We had a discussion about how she had been feeling tearful, how her sleeping pattern had changed and how she was finding it hard to cope from one day to the next. She reported feeling an intense eight out of 10 intention of self harming. But the next time we spoke her intention of self harming had dropped to two out of 10, though she was having suicidal thoughts once or twice a week.”

Jagger said that Kelsall went on to cancel two further online sessions and was told she could no longer have access to the online service and would have to wait four weeks for a face-to-face meeting.

“I told her that I would rearrange an appointment for her, but due to policy it would be the last time I could do so before she would be discharged. She told me she was struggling to complete the tasks online and agreed that it would be best to arrange a face-to-face CBT session.

“Unfortunately, due to our procedure we had to remove the option for her to access the online service because there would have been nobody available to support her. She was very concerned when we explained she would have to wait four weeks for this meeting.”

Kelsall was referred to Samantha Fox, a psychological wellbeing practitioner, and had two consultations with her. Fox told the hearing that Kelsall had experienced relationship problems in the past and her low mood was preventing her from going to work and socialising with friends.

She said: “This meant she was spending more time alone, giving her the chance to ruminate about things. She talked to me about her problem with alcohol consumption but that she felt it was something she was managing, and she also discussed her two failed relationships but never elaborated. I always felt it was difficult for her to discuss this matter, so I never knew much about it.”

But Fox said Kelsall had failed to attend two further scheduled appointments, leading to her being discharged from the service.

When asked by the coroner if Kelsall was contacted to find out why she was unwell, Fox said: “I do not believe that the admin department would ask a patient such a personal question about their health. If two or more appointments are missed, it is policy for us to send out a discharge letter. Unless there are extraordinary circumstances as to why they have been unable to attend, then they are notified that they have been dismissed from the service.”

Kelsall was found dead on 31 May 2015 after her family raised concerns for her welfare. There was no suicide note.

The coroner recorded an open verdict saying Kelsall might not have been “thinking clearly” at the time of her death. Her family were too upset to comment after the hearing.

Vicki Nash, head of Mind’s policy and campaigns, said: “A third of suicides are among people known to NHS mental health services and it is vital that when people do seek help they get the support they need. No one in touch with services, asking for help, should reach the point of taking their own life.

“NHS mental health services are under enormous pressure at the moment as funding cuts over recent years have come at a time of rising demand. As a result many people aren’t getting the right support at the right time, so they become more unwell and may reach crisis point.

“We know that suicides among people in touch with crisis teams have increased, as have suicides among people sent out of the local area for care, often because of bed shortages. It is unacceptable that the very service there to help people in crisis is unable to support people in the right way and help them to recover.

“This is why suicide prevention measures need to be accompanied by improvements to NHS mental health services. We have heard positive announcements in recent weeks about increased funding for mental health services. But without significant investment services … they won’t be able to start giving people the help they need, when they need it.”

In the UK, the Samaritans can be contacted on 116 123.

Website: www.samaritans.org

In the US, National Suicide Prevention hotline:

1-800-273-8255.

In Australia, crisis support service Lifeline: 13 11 14.

Hotlines in other countries click here