A much-loved mum and grandmother who took her own life died more than four hours after her family raised the alarm with police about her, an inquest heard.
Amelia Waterhouse, 49, was discovered hanged at her home by her daughter's partner in July 2019. She was rushed to hospital but could sadly not be saved.
Just over four hours earlier, Ms Waterhouse's sister had dialled 999 and reported a concern for her welfare to Greater Manchester Police (GMP) after she became 'hysterical' and left the hospital where she had just visited her new grandchild. Relatives had then been unable to contact her.
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An inquest into her death heard that despite the force having a one-hour target time for such calls, and a second "very concerned" call from her sister being made two hours later, no officers had been dispatched to check on her by the time she was discovered.
"No officers were available for patrol due to the high volume of calls on that day", the hearing was told.
Ms Waterhouse, who the inquest heard had a history of mental health issues and an alcohol addiction, took her own life and intended to do so, a coroner ruled as he recorded a conclusion of suicide.
However, he said the fact officers didn't carry out a welfare check on her as requested by her family was not the result of a failure by GMP but because "the resources were simply not available".
He also said "teething problems" with the police's new computer system ControlWork meant those assessing Amelia's risk following the initial call on the day of her death could not see her full history, and could also not be said to have likely affected the outcome or to have contributed to her death.
Amelia's daughter Rose told the inquest that her mum was a "very selfless person who did everything she could for her children".
"Amelia was very loving and had a sense dry sense of humour. It is clear to me that she is a much loved and much-missed member of the family" Arena Coroner Zak Golombeck said.
The inquest heard she had battled mental health problems, first being prescribed anti-depressants in 2018, as well as having issues with alcohol. And the inquest also examined her care by Greater Manchester Mental Health NHS Trust services and Manchester City Council's Early Help service.
In October 2018, she had been admitted to hospital after an intentional overdose. Her daughter Rose said that following this incident she began to 'accept help' and was engaging with an alcohol addiction service.
In May 2019 she had been pulled from a bridge and taken to hospital by police officers for a mental health assessment.
On July 23 2019, two days before her death, she was reported missing after she failed to collect her two sons, which her sister Emma Horrocks said was "unusual and worrying". Although she was later found at home.
At that time her daughter Rose was in hospital awaiting the birth of her daughter, Amelia's grandchild. She was present for the birth and was "excited about being a grandmother" the hearing was told.
However, at around 10am on July 25, she visited the hospital, had clearly been drinking and was in a "bad state". Rose told her she didn't wish her to be present if she had been drinking with Amelia heard "screaming and crying" outside the ward afterwards.
Rose then took her mum to see her daughter and they spent around an hour together having a "laugh and a joke" however she said her mother was "still very drunk" when she left.
Rose later tried to call her mother but Ms Waterhouse didn't answer and she told her auntie Ms Horrocks, who in turn called police.
During the 999 call made at 12:43pm Ms Horrocks said: 'I need someone to do a welfare check on my sister' telling the operator she had 'tried to kill herself three times in the last 12 months' and that 'this is a death waiting to happen honestly.' She added: 'I have a feeling she might well be at home just completely plastered by now but I just need to know that she's not gone and bloody dome something really stupid.'
This was categorised as a concern for welfare rather than a missing report and was given Grade 2 priority the inquest heard. At the time GMP's new ControlWorks police system had just rolled out and both the call handler and an officer from the force's Vulnerability Support Unit who assessed the log, could not see details of the incident from two days prior.
PC Philip Lever, from the force's Vulnerability Support Unit, said this may have led him to raise the case with a supervisor for possible re-grading. He filed his assessment just before 2.40pm and Amelia sent texts to friends at around 3pm meaning she was alive at or around this time the inquest was told.
The coroner Mr Golombeck said the ControlWorks system was "in its infancy and had "teething problems" and that what happened was "a failure of the system: a dysfunction that could affect the important assessments being carried out, which in turn could then determine GMP's response."
However, he said there were a "number of imponderables which in my judgement, cross the threshold of speculation" and that "I cannot find that the failure as set out, has possibly contributed to Amelia's death."
A further call by Ms Horrocks to police was made at 3:05pm in which she said she was "still very concerned" and "asked for officers ASAP." At 4.51 pm an entry on the police log said: "Patrol states checked and at this time all patrols are engaged at incidents." Just moments before this, a 999 call was made by Ms Waterhouse's daughter's partner who had found her hanged at home.
She was rushed to Wythenshawe Hospital however no cardiac activity could be found and her death was declared. A post-mortem recorded her cause of death as 1A) hanging.
"The family submit that if GMP had responded on July 25 within their target time for a Grade 2 incident, of one hour, then Amelia would likely have been found alive" Mr Golombeck said.
"Whilst this is likely correct, there is a basic flaw in this submission taking into account the evidence before me: the resources were simply not available. No failure by GMP caused a patrol not to be sent to locate Amelia."
"I am conscious the findings that I have made will come as a disappointment to the family, who have acted with tremendous respect in honouring Amelia's memory throughout these proceedings" he added.
However, he said he had "reached my findings and conclusion based on the direction the evidence has taken me."
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