Hayley Beavington, 50, died slightly before 1am on September 21 last year when she jumped from the fifth floor balcony of her flat.
On Thursday (February 20) Edwin Buckett, assistant coroner for Inner North London, issued a Prevention of Future Deaths report raising concerns about Ms Beavington’s discharge from hospital the day before her death.
Ms Beavington, who had paranoid schizophrenia and long-term substance misuse disorder, had been admitted to a North London NHS Trust hospital earlier in the month.
When planning her discharge from hospital it was agreed that the best place for her to go was a local crisis house.
There was a strong suspicion that Ms Beavington was the victim of cuckooing in her own home.
Cuckooing occurs when criminals groom a vulnerable person in order to take over their home and use it as a base for illegal activities such as drug dealing.
However, a foundation year one doctor was told by the crisis house team it was not possible to house Ms Beavington as she had secure accommodation and was no longer actively suicidal.
Mr Buckett said: “This was despite the fact that there was a strong suspicion that Ms Beavington was the victim of cuckooing in her own home; and the team view was that she was definitely at risk of suicide.
“The consultant psychiatrist in charge of Ms Beavington’s care did not give the foundation year one doctor any instruction as to how to challenge the decision that the consultant believed was wrong.
“Instead, the consultant instructed the foundation year one doctor to leave it for three days and then just try again in the same way.
“By this time, Ms Beavington decided that she had waited too long and did not want another attempt to be made. Ms Beavington was discharged home and killed herself at 1am the next morning.”
Mr Buckett added: “In my opinion, action should be taken to prevent future deaths.”
The report was sent to NHS England and the Care Quality Commission for England who must respond within 56 days.
North London NHS Trust covers Barnet, Camden, Enfield, Haringey and Islington.
Cuckooing is set to become a specific criminal offence as part of new legislation being introduced this week, carrying a maximum of five years in prison.
Currently prosecutors dealing with cuckooing cases can charge it under other offences such as assault, harassment and modern day slavery – though these may not cover all cases.
