A mum-of-two was found dead in her home after her children's school raised the alarm when she didn't arrive to collect them.
Hannah Jean Elizabeth Martin, 25, was found dead at her home on January 21 in 2019.
Daniel Walton, the dad of one of Hannah's children, smashed a window in order to gain access to the property in Bilsborrow, near Preston after a friend expressed concern for her safety, LancsLive reports.
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A two-day inquest into the death of the 25-year-old, who worked at HMP Liverpool, concluded today (October 7) with Assistant Coroner Phil Holden ruling Hannah took her own life.
During the hearing, held at Accrington Town Hall, the inquest heard Hannah, who was born in Preston, had first experienced mental health problems when she was just 13.
At 15 she took an overdose and throughout her tragically short life she received intermittent support from mental health services provided by Lancashire and South Cumbria NHS Foundation Trust.
In 2018 Hannah, who was a mum to two children who were then aged five and seven, trained as a prison officer and during the inquest mum Louise Whelan spoke of her pride in her daughter at completing the 12-week course.
Hannah started seeing another prison officer who left his wife to be with Hannah and eventually moved into her home in Bilsborrow.
But their relationship, described in the inquest by Hannah's best friend Rachel Burrow as "toxic", started to break down towards the end of 2018.
Miss Burrow described how the two women, who met at school, usually saw each other "most days" but their level of contact reduced during 2018 because her boyfriend, described as being extremely manipulative, "had an issue with our friendship".
She said said: "It was a toxic relationship, when they split up I think that because she worked with him, and had invested so much in the relationship, it wasn't easy for her to shrug it off. She wasn't herself.
"We always used to go out on little trips together, if we were just nipping to Sainsbury's for example, but around that time I remember asking her if she wanted to come with me to pick up a pram and she said 'no, I'm in bed, I'm tired'. We used to go Christmas shopping together but that year (2018) there was nothing."
By this point Hannah's mental health had deteriorated and she was "neglecting herself, not eating and losing weight", her family told the inquest.
On January 14 in 2019 Hannah's mum accompanied her to an emergency appointment with her GP Dr John Miles at Garstang Medical Practice.
Hannah had taken some notes with her, a copy of which was read out during the inquest, in which she had written details of her mental state and past treatment.
She also referenced losing weight with mum Louise Whelan noting her prison officer uniform was, at this point, "hanging off her".
Dr Miles, a GP of 12 years, told the inquest: "There was a sense of her describing a very bleak view of the future and an inability to cope."
Dr Miles was so concerned about what Hannah told him, including that she had thoughts of suicide, he called Lancashire and South Cumbria NHS Foundation Trust's mental health crisis team during the consultation to arrange for them to ring her later that day to assess her.
During today's proceedings barrister James Robottom, representing Hannah's family, told Dr Miles that Hannah's mother's recollection of the appointment on January 14 was that Hannah had told the GP she had contemplated going to assisted dying clinic Dignitas in Switzerland.
However Dr Miles said although it was possible she had said that he did not recall it and believes he would have written such a reference in the medical notes given the "connotations".
After the doctor's appointment Hannah was called by mental health nurse Cath Lupton who carried out a triage assessment and arranged for her to have a face-to-face appointment on January 31.
The inquest heard this was longer than the 10-working day maximum a patient should have to wait and Hannah's family believed she should have been referred to the crisis team in order to be seen sooner.
Best friend Miss Burrow told the inquest that Hannah had later told her the phone call was "s***".
She told the court: "She told me the crisis team didn't care and they could only give her an appointment on January 31 which [Hannah said] wasn't soon enough and she felt like it was ages off."
When asked what difference it would have made if Hannah had been seen face-to-face sooner her mum Louise Whelan said: "I think it would have saved her."
On the afternoon of January 21 Daniel Walton, the the father of one of Hannah's children, was called by their school to let him know Hannah had failed to collect her son and daughter.
After dropping off the two children with Hannah's mum Mr Walton and Miss Burrow headed over to Hannah's house where they found her dead in the bedroom.
A medical cause of death was given as toxicity caused by an overdose of medication.
The inquest heard that on January 19, two days before she was found dead, Hannah had sent an email to Switzerland-based assisted dying clinic Dignitas in which she wrote: "I want to die. I don't want this life I have been given."
The coroner concluded Hannah's death was a suicide and described it as "an extremely tragic case".
Mr Holden said: "This was a mum-of-two who lost her life at the age of just 25."
Although the coroner said he accepted Dr Miles' evidence in what he passed onto the mental health team in requesting an urgent referral for Hannah, Mr Holden said he was of the view that the mental health nurse "did not likely record that she was told by Dr Miles of Hannah becoming disassociated".
The coroner said: "The fact of that disclosure rendered it more likely that there would have been a referral to the crisis team.
"However, that said, even if there was a referral to the crisis team I find it simply not possible to say, on the evidence that I have heard, whether or not that would have had any effect on the eventual outcome in this case."
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