How the State Facilitated The Suicide of a Rochdale Rape Gang Survivor
Charlotte Tetley Told Them She Would Die. They Made Sure She Did.
When Charlotte Tetley walked into A&E in June 2024 and told staff she was thinking of jumping in front of a train, she was reviewed daily for a week. Then, on 25 June at 10:37, she was removed from the inpatient bed list before a qualified mental health professional even saw her. Two months later, she sat down on railway tracks in Macclesfield and was killed by a train.
This was not inevitable. This was not a tragedy. This was a state sanctioned killing.
Charlotte Tetley was a survivor of the Rochdale grooming gangs. That fact was not a footnote. It was the foundation of everything that followed. The trauma, the drugs, the instability, the despair. The system knew all of this. And still, at every stage, they failed her.
The First Failure: Survivors Were Abandoned After the Trials
The courts convicted some men and politicians declared victory, eager to move on from the uncomfortable truth of their own failings. The girls were abandoned. There was no lifelong safeguarding plan, no trauma-informed support network, no stability built around the reality that these survivors had endured the worst kind of violence. Charlotte and girls like her were left to carry the scars while the state moved on.
Charlotte was diagnosed with Emotionally Unstable Personality Disorder and had previously been diagnosed with Post Traumatic Stress Disorder and substance misuse causing behavioural and mood disorder. These were not pre-existing conditions. These were the direct psychiatric consequences of organised child sexual abuse. The medical labels described what the state had already failed to prevent.
The coroner recorded that drug dependence was a coping mechanism. Not a lifestyle choice. Not recreational use. A survival strategy for managing unbearable trauma. Yet Charlotte was managed through probation services and drug and alcohol teams, not through dedicated CSE survivor support. She was treated as an offender managing addiction, not as a victim requiring specialist trauma therapy.
The Rochdale grooming gang prosecutions ended. The news cycle moved on. The politicians took credit for justice delivered. But for Charlotte, there was no moment when the abuse stopped having consequences. There was no support structure designed to last as long as the trauma did. She was expected to rebuild her life with the same fragmented, inadequate services available to any person with mental health difficulties and substance misuse, as if the organised sexual exploitation and torture of her childhood was just one more item on a clinical checklist rather than the defining catastrophe of her existence.
The Second Failure: Her Abuser Was Allowed Back While She Was Forced Out
In July 2023, one of Charlotte's abusers was allowed to return to Rochdale. Not to a different town or supervised accommodation, but home. To her home. Charlotte was the one forced to leave. She lost her community, her support network, everything she knew, so her abuser could have his life back. The rights of a convicted abuser were prioritised over the rights and safety of his victim.
This was not an administrative oversight. This was a policy choice. Somewhere in the probation service or the Multi-Agency Public Protection Arrangements, officials decided that an offender's right to return to his preferred location outweighed a victim's right to remain in hers. No risk assessment concluded that Charlotte would be better off displaced. No safeguarding professional argued that uprooting a trauma survivor from her established support networks would improve her outcomes. The decision was made because the system protects offenders' rights by default, and victim's rights only when convenient.
Charlotte had been under Rochdale mental health services. She knew the area. She had whatever fragile stability a grooming gang survivor can build. Then in July 2023, she was transferred to Macclesfield Community Mental Health Team because her abuser came back. Think about what that means in practice. New clinicians who didn't know her history. New support workers learning her case from files. New accommodation in an unfamiliar area. Every connection severed because the state decided her rapist's preference mattered more than her recovery.
The coroner recorded this fact plainly in her report without editorial comment, but the implication is devastating. The very act of forcing Charlotte to move was a continuation of her abuse. She was victimised as a child and then victimised again as an adult when the state chose her abuser over her.
The Third Failure: Homelessness and Instability
Charlotte ended up in Macclesfield with no secure housing. The coroner recorded it plainly when she noted that Charlotte's ability to take prescribed medication was influenced by whether she had accommodation. Without a roof she had no treatment and no stability. For a grooming gang survivor already battling trauma, this instability was devastating. There was no trauma-informed housing pathway for survivors forced to relocate.
The relationship between accommodation and medication compliance was not incidental. Charlotte had been prescribed medication to manage her Post Traumatic Stress Disorder and Emotionally Unstable Personality Disorder. But psychiatric medication requires routine. It requires somewhere to store it safely. It requires the cognitive capacity to remember to take it, which is difficult when you are dealing with the chaos of not knowing where you will sleep. The coroner's finding that Charlotte's "concordance was sporadic and influenced by whether she had accommodation" is a clinical way of saying the state made it impossible for her to follow her treatment plan.
On 24 June 2024, the bed management meeting minutes recorded that the Home Treatment Team did not think Charlotte required a mental health inpatient bed but that "the homeless pathway needed to be explored before taking off the inpatient list." This acknowledgment that Charlotte was homeless or at risk of homelessness was documented in an internal meeting but crucially, it was not recorded in Charlotte's clinical records that day. The people making decisions about her housing knew she was homeless. The people making decisions about her mental health care were not told.
Even when Charlotte was deemed well enough to be discharged from the inpatient bed list, the plan was to admit her to a medical ward to address homelessness. Not to house her. To admit her to a hospital bed because the state could not provide her with actual accommodation. This is what we have come to. A woman became homeless by being forced out of her home because her abuser was being prioritised.
The Fourth Failure: She Begged For Help and Was Ignored
On 18 June 2024, Charlotte walked into the Accident and Emergency Department at Macclesfield Hospital voicing concerns for her safety and thoughts of jumping in front of a train. The clinical team found that an informal admission was clinically indicated to commence depot injection and to maintain safety. She was reviewed daily from 18 June until 24 June. On each day, the clinical records document that an informal admission was necessary. On 24 June, the clinical records note that Charlotte herself felt "the only option for her to get better was for admission."
Then on 25 June at 10:37 hours, Charlotte was discharged from the inpatient bed list by the bed management team. This happened before an attempted review by a Mental Health Practitioner at 11:30 hours. A handover had been obtained from Accident and Emergency nursing staff who reported no concerns or change in presentation. The practitioner concluded that Charlotte did not appear to require a mental health inpatient admission but might benefit from an admission to a medical ward to address homelessness.
Read that sequence again. For a week, every single daily review documented that Charlotte needed inpatient admission. She had directly stated she wanted to jump in front of a train. She had told clinicians that admission was the only way she would get better. Then, on the morning of 25 June, the bed management team removed her from the inpatient bed list. An hour later, a Mental Health Practitioner attempted to review her, found her asleep, and decided not to wake her for a proper assessment. Instead, the practitioner relied on a handover from nursing staff and concluded she didn't need admission after all.
Charlotte left the Emergency Department at 12:57 hours. Immediately after discharge, she called her probation officer and was noted to be screaming down the phone, stating she was going to the railway line to kill herself. She also phoned her family expressing dismay about being discharged from the inpatient bed list. The community Consultant Psychiatrist and other mental health practitioners had documented concerns about the safety of the discharge. Their concerns were noted. Charlotte was still not admitted.
She directly disclosed suicidal intent. She was assessed for a week. Every assessment said she needed admission. Then a bed management team overruled clinical judgment, and a practitioner who didn't even wake her for a face-to-face assessment decided she was fine. Hours later she was screaming that she was going to kill herself. The system heard her and did nothing.
The Fifth Failure: Multiple Suicide Attempts Were Not Treated As Emergencies
After Charlotte was discharged on 25 June and immediately told her probation officer she was going to the railway line, her whereabouts were unknown to the community mental health team until 2 July when they were contacted by her probation officer. On 3 July, Charlotte received a psychiatric review by a Specialist Registrar, who concluded that there was no clinical indication for a mental health act assessment or informal admission.
Let that sink in. Charlotte had been deemed in need of admission for seven consecutive days in June. She had been discharged against clinical advice. She had immediately stated she was going to kill herself on railway tracks. She had then gone missing for a week. When she was finally reviewed again on 3 July, the psychiatrist decided she did not need admission.
The coroner's report notes that Charlotte subsequently engaged with the community mental health team and community drug services, suggesting she was at least trying to access the support available to her. But on 18 September 2024, she was removed from railway tracks by British Transport Police. This was not a threat. This was not a gesture. Charlotte was physically on railway tracks. She had to be removed by police. She had reported feeling suicidal to workers who had found her.
She was taken to the Accident and Emergency Department of Macclesfield Hospital. She left before being reviewed by the Mental Health Liaison Team. Still, no inpatient bed was offered. Still, the professionals convinced themselves she could be managed in the community.
Charlotte had taken multiple previous overdoses with intent to end life, as the coroner recorded. By September 2024, she had been found on railway tracks once and had expressed repeated suicidal ideation over months. Each incident was treated as a discrete event rather than part of an escalating pattern. Each time, the risk was assessed and downgraded. Each time, community management was deemed sufficient. Multiple suicide attempts were treated as manageable risks rather than medical emergencies requiring immediate intervention and long-term inpatient stabilisation.
The Sixth Failure: Emergency Services Refused to Respond
On 18 September 2024, after Charlotte left the Accident and Emergency Department before being reviewed by the Mental Health Liaison Team, staff contacted the police to report her as a high-risk missing person. The police informed them that under the Right Place, Right Person policy, nobody would be deployed.
The Liaison Psychiatry Clinical Lead requested for this to be escalated to a supervisor and spoke directly with them. She expressed concerns about an immediate risk to safety for Charlotte. The police supervisor maintained that nobody would be deployed. Their reasoning was that because Charlotte had not voiced an intention to end her life when she left the department, it could not be known that this was her intention.
The Liaison Psychiatry Clinical Lead explained that the fact Charlotte was not engaging had concerned her more about her immediate safety. This is a clinician telling police that a known high-risk patient, just removed from railway tracks hours earlier, refusing to engage with mental health services, is in immediate danger. The police response was to suggest that an ambulance response vehicle should go out instead.
The ambulance service was contacted to request a response vehicle. The Clinical Lead was informed that as the whereabouts of Charlotte was unknown, they would not deploy anyone. So there it is. Police will not respond because she has not explicitly stated intent. Ambulance will not respond because her location is unknown. A grooming gang survivor, known to services, with a history of suicide attempts, just physically removed from railway tracks that same day and now flagged as high-risk and missing. Both emergency services abdicated their safeguarding duty to respond to a woman in crisis.
ByStewart Whittingham
This was not a resource issue. This was not a matter of competing priorities. This was a policy decision. The Right Place, Right Person policy, designed to reduce inappropriate police deployments to mental health incidents, was being used to justify leaving a high-risk woman with no emergency response at all. The Liaison Psychiatry Clinical Lead had done everything right. She escalated. She explained the risk. She requested deployment from both emergency services. Both refused.
Charlotte's keyworker was able to contact her by telephone on 18 September and arranged to see her the following day. Charlotte was reviewed by her keyworker on 19 September. The keyworker kept her alive. Not the police. Not the ambulance service. A keyworker, with no power to detain, no emergency response capability, just a phone call and an appointment. That is what stood between Charlotte and death that day. Not the state. One person doing their job while two emergency services walked away.
The Final Day
On 19 September, when Charlotte met with her keyworker, she requested that an outpatient appointment with her psychiatrist be rearranged from 24 September because she had a court hearing that day. She was still trying to manage her life. Still trying to attend appointments. Still engaging with the system that had failed her repeatedly.
On the morning of 24 September 2024, Charlotte did not attend her court hearing. She spoke by phone with her mental health keyworker and expressed longstanding suicidal ideation without immediate intent. Later that day she attended the office of the community drug and alcohol team, where staff noted she was tearful and in a low mood. She was still reaching out and still telling people, but nobody stopped her.
These were not subtle warning signs. Charlotte was tearful, in low mood, expressing suicidal thoughts, and had missed a court hearing. Every indicator pointed to someone in crisis. She had attended a drug and alcohol service that same day, meaning she was trying to access help. She had spoken to her keyworker that morning. She was visible to services right up until the moment she died.
The coroner recorded that Charlotte was later fatally struck by a train when she deliberately sat on the tracks. There was no easy access to the tracks at that point, meaning Charlotte had to make a deliberate effort to reach them. This was not an impulsive act. She walked there. She sat down. She waited.
Charlotte Tetley spent the last day of her life in contact with mental health services and drug and alcohol services. She told professionals she was suicidal. She was observed to be tearful and low. And then she walked to the railway tracks in Macclesfield, sat down, and waited for the train that would kill her.
On 25 June, she had told services she was going to jump in front of a train. On 18 September, she had been physically removed from railway tracks. On 24 September, she went back. She had told them exactly what she would do. They did not stop her.
The Coroner's Warning
Coroner Sarah Murphy issued a Regulation 28 Report to Prevent Future Deaths on 14 September 2025. This is not a formality. This is a legal instrument used when a coroner believes there is a risk that more people will die unless action is taken. The coroner stated explicitly in her report that during the course of her investigation, her inquiries revealed matters giving rise to concern, and that in her opinion there is a risk that future deaths could occur unless action is taken.
Her specific concern was documented clearly. Charlotte was removed from the inpatient bed list on 25 June at 10:37 hours before an attempted review by a mental health practitioner at 11:30 hours the same day. Following daily documented reviews between 18 June and 24 June, every single one recording that Charlotte required inpatient admission and daily reviews, she was taken off the list by a bed management team before a qualified mental health professional conducted a proper review.
The coroner wrote that she is concerned there is a risk that patients are removed from the inpatient bed list before an appropriate review that day by a mental health professional. This is not speculation. This is a coroner stating on the record that the same systemic failure that contributed to Charlotte's death is still in place and will kill other patients unless it is fixed.
The report was sent to the Chief Executive of Cheshire and Wirral Partnership NHS Trust under the coroner's statutory duty. They have 56 days from 14 September 2025 to respond, meaning a deadline of 9 November 2025. Their response must contain details of action taken or proposed to be taken, setting out a timetable for action. If they propose no action, they must explain why.
As of now, that response is still pending. The coroner has made her finding. She has identified the systemic risk. She has stated clearly that future deaths could occur. The NHS Trust has been given a legal deadline to respond. And while we wait for that response, the same bed management processes that removed Charlotte from the inpatient bed list before a proper review are still operating. The same policies that allowed emergency services to refuse deployment are still in force.
Coroner Sarah Murphy did not simply record a conclusion of suicide. She used her legal powers to issue a warning that more people will die unless the system changes. The question now is whether anyone with the power to make those changes will act before another Charlotte Tetley tells services she is going to kill herself and is ignored until it is too late.
This Is Our Victoria Climbié Moment
Victoria Climbié was seen 128 times by authorities before they let her be murdered. Social services visited. Police investigated. Health professionals examined her injuries. Every agency documented concerns and then failed to act. When she died in 2000, the systemic failures were so catastrophic that Parliament had no choice but to respond. The Children Act 2004 rewrote child protection law, imposed new statutory duties on every local authority, and forced agencies to share information and coordinate safeguarding.
Charlotte Tetley was seen over and over by A&E, probation, mental health teams, police, ambulance. She was reviewed daily for a week in June 2024, with every review documenting that she needed inpatient admission. She told them she wanted to jump in front of a train. She was found on railway tracks by police. She called her probation officer screaming that she was going to kill herself. She phoned her family expressing dismay at being discharged. She attended drug and alcohol services tearful and in a low mood on the day she died. She told them what she was going to do. They knew her history. They had her risk assessments. They documented their concerns in clinical records. They watched her walk toward death and did nothing.
This is the same scale of systemic failure. Multiple agencies. Multiple interventions. Multiple documented warnings. And still, the person everyone knew was at risk died exactly as they predicted. It demands the same scale of reform.
But there is a difference, and that difference explains why we are still waiting for the government to act. Victoria Climbié was one child. Her case was a scandal but it was containable. The politicians could condemn the specific failures, pass legislation, and move on without confronting anything structural about how the state treats vulnerable children.
Charlotte Tetley is one of tens of thousands of victims. The grooming gang survivors are overwhelmingly White working class girls, and the state has covered up their abuse for decades. This is not one tragic case. This is an entire cohort of children who were systematically failed by every institution that should have protected them, and who continue to be failed as adults.
In January 2024, a review revealed that girls in Rochdale were left at the mercy of Pakistani Rape Gangs for years because of failings by senior police and council bosses. The review examined 111 cases from 2004 to 2013 and found that 74 children had a significant probability of being sexually exploited, with serious failures to protect them in 48 cases. The review detailed multiple failed investigations by Greater Manchester Police, including how in 2007, despite being explicitly alerted to an organised crime group dealing in child sexual exploitation, GMP and Rochdale Council chose not to progress any investigation.
But Rochdale was not unique. In Rotherham, an estimated 1,400 girls were subjected to group-based child sexual exploitation from the late 1980s until 2013. The National Crime Agency investigation into Rotherham identified more than 1,100 victims and hundreds of perpetrators in their nine-year investigation. That is one town. Similar patterns of organised abuse and institutional failure have been documented in Telford, Oxford, Oldham, Newcastle, Huddersfield, Bradford, and nearly 100 other locations across England.
How many children in total? How many girls were groomed, raped, trafficked, and then abandoned by the state across every town where this occurred? Nobody knows. There has never been a comprehensive national audit. The true scale has been deliberately obscured. But we know it is tens of thousands. We know that Charlotte Tetley was one of tens of thousands, and that most of them are still alive, still traumatised, still failed by the same systems that failed them as children.
Victoria's case was easier. The politicians could express horror and take action without admitting their own complicity in a decades-long cover-up motivated by political cowardice and institutional racism against the White working class. Here, reform means admitting what they have spent years denying and burying. It means confronting why thousands of girls like Charlotte were ignored when they reported abuse, why their abusers were allowed to operate with impunity, why police and social services prioritised community relations over child protection, and why even now, after convictions and inquiries, the survivors are still being abandoned.
That makes it harder. The political class does not want to open that wound. They do not want to acknowledge the scale of what was done, or what continues to be done, to grooming gang survivors. But Charlotte Tetley died on 24 September 2024 after telling services exactly how she would die. The coroner has warned that more deaths will occur unless action is taken. The difficulty of confronting this scandal does not make reform optional. It makes it urgent.
Charlotte's Law
The coroner has issued her warning. The comparison to Victoria Climbié is unavoidable. The question now is what Parliament will do. After Victoria died, the government passed the Children Act 2004 within four years. That legislation created statutory duties, imposed mandatory cooperation between agencies, and fundamentally changed how the state protects children. We need the same response now. We need Charlotte's Law.
This cannot be another consultation. It cannot be guidance that agencies can interpret away. It cannot be targets that look good in press releases but have no enforcement mechanism. Charlotte Tetley was killed by a system that documented every failure, held meetings about her care, assigned her to multiple services, and still allowed her to die. Guidance did not save her. Targets did not save her. Only binding legal obligations with consequences for non-compliance will prevent the next death.
Parliament must pass Charlotte's Law with the following provisions.
- First, a statutory lifelong duty of care for all child sexual exploitation survivors. No more aging out of support when the headlines fade. Every grooming gang survivor must be designated a vulnerable adult with an assigned lead professional responsible for coordinating their care across all agencies for life. This is not optional. This is not resource-dependent. This is a legal duty owed to every person who was failed as a child.
- Second, housing protection guarantees. No survivor can be displaced because an offender returns. No survivor can be made homeless. The state forced Charlotte to leave Rochdale so her abuser could return. That must be made unlawful. Any offender release or return that would displace a survivor must be blocked, or alternative accommodation for the offender must be found. The victim's right to remain in their home and community is absolute. No exceptions.
- Third, mental health bed list protections. Any patient flagged suicidal cannot be removed from an inpatient bed list without face-to-face assessment by a qualified clinician. No administrator, no triage nurse, no non-clinical staff can make that decision. The coroner identified this specific failure. It is the easiest to fix. It must be legally mandated within 90 days of this law passing, with criminal penalties for NHS trusts that fail to comply.
- Fourth, mandatory trauma-informed care and decriminalization. Survivors whose drug use or offending stems directly from abuse and exploitation must be diverted from the criminal justice system into therapeutic support. Charlotte was managed through probation and drug services as if she were a criminal managing addiction. She was a victim trying to survive. The default assumption for all grooming gang survivors must be that their substance use and offending is trauma-related, and the burden of proof must lie with the state to show otherwise before any criminal sanction is imposed.
- Fifth, mandatory multi-agency coordination with a single point of accountability. Every CSE survivor must have a named lead professional responsible for coordinating all support and intervention across mental health, housing, probation, drug services, and any other agency involved in their care. No more cases where everyone knows the victim and nobody owns the care. That lead professional must have statutory authority to compel cooperation from other agencies and must be personally accountable if coordination failures contribute to harm.
- Sixth, high-risk missing protocols with teeth. When someone is flagged as high-risk missing, emergency services cannot decline to respond. Active search and welfare checks must happen within a defined timeframe set by regulation. No policy discretion that allows services to walk away. If police or ambulance services are contacted about a high-risk grooming gang survivor and refuse to deploy, that refusal must trigger an automatic review by the relevant chief officer within 24 hours and a report to the coroner if the person subsequently dies.
- Seventh, emergency services reform. Right Place, Right Person policies cannot be used to refuse response to high-risk CSE survivors. The policy may be appropriate for some mental health incidents, but it cannot apply to anyone with a history of child sexual exploitation and documented suicide risk. That category of person must trigger automatic deployment. No supervisor discretion. No case-by-case assessment. Deployment must be mandatory and refusal must carry disciplinary consequences.
Not guidance. Not targets. Law.
Charlotte Tetley told the state she was going to die. She told them repeatedly, explicitly, desperately. She was reviewed, assessed, documented, and managed right up to the moment she sat down on those railway tracks. The system did not lack information. It lacked the legal obligation to act on that information. Charlotte's Law must create that obligation, with enforcement mechanisms that ensure the next survivor who tells services she is suicidal will be saved rather than filed.
Victoria Climbié's death gave us the Children Act 2004. Charlotte Tetley's death must give us Charlotte's Law. Anything less is a decision to let more survivors die while we pretend the system can fix itself. The coroner has warned us. The evidence is documented. The reforms are specific and achievable. The only question is whether Parliament values the lives of grooming gang survivors enough to act.
There are politicians across every party who have found their voice on grooming gangs in recent months. There are political commentators who have built careers condemning the cover-up. There are journalists who have reported extensively on the scandal. If they are genuine in their concern for victims, they will support Charlotte's Law. If they meant what they said when they condemned the failures of Rochdale, Rotherham, Oldham, Telford, and every other town where girls were abandoned, they will demand this legislation.
This is the test of sincerity. It is easy to express outrage about historic failures. It is easy to condemn officials who are no longer in post. It is easy to demand inquiries that take years and change nothing. Charlotte's Law is concrete. It is specific. It is achievable. Supporting it means accepting that the scandal did not end with prosecutions, and that survivors are still dying because the state still fails them.
Every MP who has spoken about grooming gangs should be asked whether they support Charlotte's Law. Every commentator who has written about the cover-up should be asked whether they back these seven provisions. Every journalist who has covered the trials should be asked whether they will campaign for this legislation. Their answers will tell you whether their concern was genuine or whether it was just another opportunity to perform outrage without demanding change.
Charlotte Tetley died on 24 September 2024. The next survivor is in crisis right now. She is sitting in an A&E department being assessed for the third time this month. She is on the phone to her keyworker saying she cannot cope. She is standing on a bridge looking down. How many more names do we need before we pass this law? How many more inquests? How many more coroner's warnings? How many more women have to die exactly as they said they would before we make it illegal for the state to ignore them?
They silenced victims. They erased evidence. They persecuted whistleblowers, discredited survivors, buried official reports, and protected predators. They thought no one would fight back and that they had got away with what they did. They were wrong.
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