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A mother who drowned in a river after struggling with post-natal depression should have received more help from mental health authorities, a coroner has said.
Victoria Taylor, 34, vanished from her home in Malton, North Yorkshire at around 9am on September 30 last year. She was found three weeks later in the River Derwent after a series of failings by authorities.
The mother had struggled with post-natal depression and drank heavily as a coping mechanism to deal with childhood trauma, an inquest heard.
Area Coroner for North Yorkshire and York, Catherine Cundy, raised concerns about the lack of co-ordination between mental health services following the tragic death of Ms Taylor and warned they must work together.
A coroner said that Ms Taylor, known as Vixx, entered the water intentionally, but did not conclude she was intending to end her life.
In a tribute, Emma Worden said her 'fiercely loyal sister' was failed by 'systemic neglect' from mental health services.
Ms Taylor had three separate assessments of her mental health by crisis and acute health teams who concluded that there was nothing further that they could do.
Ms Cundy questioned whether NHS mental health services had 'missed opportunities' to intervene, after learning Ms Taylor had previously expressed suicidal thoughts.
Ms Taylor had been rescued from the same river just three months earlier after entering while drunk - when the water was both warmer and shallower. The Derwent was in full spate at the time of her death due to heavy rain.
She saw her GP in the days following the incident when he again referred her for crisis assessment.
He recorded in his notes that she had placed herself 'in the river with the intention of ending her life'.
Despite this, she was later advised to self-refer to a private psychological service if she felt distressed again.
On another occasion in May 2024, she was referred to the crisis team after being found crying in the street and telling a friend she planned to jump in the river.
The crisis team met with Ms Taylor the following day and concluded 'there was no role for mental health services,' instead suggesting lower-level talking therapies.
Secondary mental health services were not involved following these assessments, and the agreed action plans added no support to what Ms Taylor was already receiving.
The 34-year-old told assessors that her self-harm and binge drinking was the direct result of childhood trauma, but there was no discussion of addressing this.
When was suggested at the second assessment that she try a private psychotherapist, there was no rationale for why this would be appropriate.
She told mental health professionals that she'd left a message with this private provider and had no reply, but they simply said that she should try again.
A further assessment occurred on August 20 when she was taken to the emergency department for a check up after her fiancé found empty packets of pills.
She had been found in a field in the town by her brother after one of her sisters was contacted by text to say what she had done.
She was taken to hospital with a suspected overdose. She was 'tearful and low in mood and drinking three bottles of wine to cope with distress', it was said.
Ms Taylor told paramedics she had taken the pills because she wanted to die but then felt 'silly for taking it because it was an impulsive act'.
These assessments took place between May and the end of August 2024.
She went missing at the end of September and her body was discovered from the river on October 22.
Ms Cundy sent a report to the Tees Esk & Wear Valley NHS Trust calling for it to ensure its mental health agencies cooperate more closely.
She said a multi-agency approach or meeting could have facilitated a more appropriate support plan for the 34-year-old.
If the agencies cooperate on support plans they may be able to prevent future deaths, Ms Cundy added.
The coroner said: 'Ms Taylor was assessed on three separate occasions between mid-May 2024 and the end of August 2024 by members of the Crisis and Acute Hospitals Liaison Teams.
'Ms Taylor was clear during all three assessments that her episodes of binge drinking and impulsive acts of self-harm were the result of unresolved childhood trauma.
'Despite that, secondary mental health services considered there was no role for them in offering support or a treatment pathway to her.
'The safety plans agreed following these assessments were therefore limited and offered Ms Taylor no additional support beyond that which she was already accessing through the Horizons service.
'The assessment documents contained no discussion of treatment pathways for addressing trauma which might be accessed through the Community Mental Health Team, and no indication that such pathways had been offered to Ms Taylor and rejected by her.
She continued: 'Mental Health services were aware at the time of the second and third assessments that a number of agencies were involved with Ms Taylor, but no multi-agency meeting or approach was suggested or called by them to consider the most appropriate support for Ms Taylor.'
The coroner also sent the report to Horizons Scarborough, which was providing support to Ms Taylor, Derwent Practice (Malton), the Department of Health and Social Care, and the Chief Coroner.