Susan Carter, of Florida Avenue, was found dead in her home in May following an overdose of nortriptylin medication she had been taking to manage long-term depression. The retired pastry chef had been admitted to hospital in Peterborough on April 4, before being discharged for home treatment four days later something her family believe was the wrong decision. Dr Damaris Koch, a consultant psychiatrist who treated Mrs Carter, said: The idea is the patients are treated at home and extend their hospital stay with intensive treatment at home. We are short of resources and psychiatric beds in the country and this is our trusts approach to making it work. Although Mrs Carter stayed until April 8, the unit has a 72-hour assessment period in which doctors have to decide how to proceed a pressure which Dr Koch admitted impacts on patients. Dr Koch told Lawrence Court, in Huntingdon, Mrs Carter was anxious to leave but that she was engaging well with conversation before her discharge. I did not feel there was much more we could have achieved by a longer admission, she said on November 17. She had been fairly reluctant to engage with ward activities. I did not feel extending it would have made much of a difference and thought home treatment would be more beneficial at that point. Mrs Carter, who volunteered at Wood Green, had support from a nurse and a crisis resolution home treatment team while she was at home, but her depression continued to fluctuate. She met with a psychologist who also thought she had post-traumatic stress disorder following dreams and flashbacks about her dead son and husband. By May, though, Mrs Carter told her nurse she was struggling to do things at home and that her house was a mess like her head. Although she was offered to return to hospital, she refused, and a neighbour was called to identify her body on May 19. After her death, a serious incident report was launched into Mrs Carters care, with a self-referral system put in place across the Cambridgeshire and Peterborough Foundation Trust. Ward management at the hospital which saw Mrs Carter has also been asked to look at its support system, as well as another team involved in her home treatment. David Heming, senior coroner for Cambridgeshire and Peterborough, concluded Mrs Carter had taken her own life, and says he will write to the Secretary of State for Health to address the issue of resources. He said: Im a small fish in a big pond but the more coroners who do that, the bigger the impact. Its budget-driven and has to be at the moment, and its a difficult one to crack. But a clinician says honestly and candidly that it does have an impact on patient safety and risk of other deaths.