Jane Kavanagh, 33, had been a full time carer to her 15-year-old daughter who was autistic and suffered from the degenerative condition Cerebral Ataxia.
But despite living on her own with her two children, Miss Kavanagh had no care workers assigned to her. There were also no adaptations made to her house and she was never offered respite care.
While her parents did offer support, their house was deemed "inadequate" by local authority officials in Rochdale, Greater Manchester and Miss Kavanagh and the children had to move to a property described by family members as "appalling".
She took her life on April 21 this year having earlier left the children with her parents Alan and Irene Farrar.
Just 24 hours before her death Miss Kavanagh, who had been prescribed antidepressants, called her GP surgery and explained she had suicidal thoughts. But she was only offered an appointment for 12 days later.
At the Heywood hearing Mrs Farrar wept as she said: ''Jane was 19 when her first child was born and she had some difficulty with getting assistance from the authorities and she became her full time carer.
"Her eldest was diagnosed with autism but it took a few years for the authorities to accept that. She then started having trouble with her leg which got worse and worse and she was diagnosed with cerebellum ataxia in 2015 – she was just 12 and had lots of hospital appointments in Manchester and one in London.
''We helped when we could and they all used to live at our house, but they conducted a review and moved them out to a bungalow and her daughter moved to a specialist school. Jane wasn’t getting assistance at weekends or evenings.
"She was offered no respite. Her other daughter had some assistance from her dad.
"She wanted help for in the mornings, getting them washed and dressed and ready for school. She was looking after two children essentially on her own and she struggled. At first she was staying with us and her two children and there were no adaptions to the house or anything.
''She then went to a rented bungalow, but there wasn’t enough room for them all, so she was told to go to this new address as they said there was nothing else available. It was a mess, the walls were covered in nicotine, it was in an appalling state. She had to paint it and clean it herself.
"There was nothing there for her daughter, no adaptations to the bathroom, the bedrooms were upstairs, there wasn’t even a grab rail for the stairs. She had to shuffle on her bum to get upstairs. She spent the last 15 months in that property.
''She lost a lot of weight and she sometimes rang up distressed and said she felt she would end up in a psychiatric ward. We were concerned about her drinking, she was drinking a lot. She had financial issues too.
"On April 21 we had her daughter stay over on the Friday night. Jane then came over the Saturday morning to pick her up. She got her about lunch time and then came back at teatime. She told us she had eaten, so she had something. She seemed to be in a happy mood.
"Jane then asked to go to her friends and promised she would be back for 8pm. She didn’t come back. We expected her to stay over. Her daughter rang her, but her phone was off.
''Now we now have the same problems Jane had. Her daughter can wheel herself around but she needs constant care 24/7.''
Mr Farrar said: "We were absolutely devastated. We knew she had financial difficulties but no idea how bad. I went to the bank the day after she died and found that she had been transferring money to different people over the previous six months."
Miss Kavanagh's GP Dr Ayman Ramadan said: "In March 2018 she was talking about feeling depressed and her mother came with her. Although she seemed well, she was low in mood and was encouraged to self refer herself to ‘Healthy Minds’ so she could help herself.
''She rang the surgery on April 20 and wanted an appointment. The receptionist used the triage system and made the appointment for May 2. At the time there were no red flags with how she was behaving.''
Recording a conclusion of suicide Coroner Nicholas Flanagan said: "I am extremely concerned by all of the evidence I have heard about the non-clinical staff at the GP surgery.
"There is a real pressing concern that someone can ring up in relation to an appointment and not be seen or considered by a clinic member of staff for a significant period of time. This is a real concern.''
Mr Flanagan said he wanted hear from NHS officials over the possibility of a Prevention of Future Deaths report being produced.
Speaking after the hearing, Irene said: "We feel like we’ve got no answers. We feel like we’ve got no closure. Our next step is to get the right adaptations into the house for our granddaughter. We understand what Jane had to do and how tough it was for her."
If you are affected by any of the issues raised in this article, please call the Samaritans on 116123.
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