A young woman with a history of mental health problems died after being hit by a car while she was sat in the middle of the road, an inquest heard.

Antonia St Louis, 27, suffered 'unsurvivable injuries' after the crash in Ashton-under-Lyne, Greater Manchester, in the early hours of 28 November 2020.

An inquest at South Manchester Coroner's Court heard Miss St Louis and a friend were walking along Manchester Road, near Snipe Retail Park, before walking onto the carriageway.

They stopped in the middle of the three lanes, with CCTV footage showing Miss St Louis, a beautician, sitting on the floor.

She was hit by a Volkswagen Golf being driven by Andrew Copeland at around 3:40am. 

No charges were brought against Mr Copeland, who stayed on the unlit road to assist police.

Miss St Louis died at the scene, the inquest heard. 

Pathologist Dr Charles Wilson said alcohol and cocaine were found in Miss St Louis' system.

Forensic collision reconstruction officer PC Paul Terry told the court Mr Copeland was travelling at around 40mph at the point of collision, and, due to the dark conditions at the time, did not have enough time to react.

Dr Wilson said the fractures and internal injuries sustained led to Miss St Louis dying 'quickly'. 

He gave her medical cause of death as 'chest injuries'.

The court heard from a number of mental health professionals regarding issues around Miss St Louis' mental health in 2020.

Coroner Adrian Farrow and Miss St Louis' family raised concerns over some aspects of her care, including her discharge from a mental health ward to a home-based team at the end of September.

Her subsequent discharge from that arrangement was also explored as there was a delayed transfer of care to the Tameside Community Mental Health Team.

Concerns were raised around a delay in appointing a care coordinator to stay in contact with Miss St Louis.

Mr Farrow said he believed a referral should have been made to a drug and alcohol service, which was mentioned in notes from various clinicians, but never actioned.

In September 2020, Miss St Louis was sectioned, the inquest heard. 

She was in this care for more than a week as her mental health improved.

She was discharged from the Medlock Ward of Trafford General Hospital's Moorside Unit on September 28 to a home-based treatment team.

Sara Dalglish, a ward manager at the Medlock Ward, said Miss St Louis' mental state improved during her time on the ward and the patient became more aware of the impact drinking alcohol and taking drugs would have on her mental health.

Miss St Louis had meetings with home-based teams during early October and was considered as posing a low risk to herself and others, but was discharged on October 20 after making threats to staff of this service and missing two weeks of meetings.

She then saw Laura Kamal from the community mental health team based in north east Manchester, who said she had 'no immediate concerns'.

Ms Kamal did have concerns about her transfer of care to Tameside Community Mental Health Team, which had been delayed since her discharge from the home-based team.

Mark Hynes, from Greater Manchester Mental Health NHS Foundation Trust, said a serious incident review was carried out. 

He accepted Miss St Louis' transfer should have been completed sooner.

Mr Hynes said: 'We would have expected a care coordinator to have been put in place at that time [after discharge].'

Mr Farrow said a referral to drug and alcohol services appeared to have been necessary, but Mr Hynes said there was 'nothing to suggest a referral had been made'.

He agreed with the coroner that a coordinator to oversee Miss St Louis' care and the transfer to the Tameside team would have been beneficial, but 'just didn't happen'.

Mental health service manager Glyn Hulme, who wrote an action plan following the case, said changes had been made to address the 'gap' in Miss St Louis' care, including more thorough risk assessments being carried out; and ensuring more admin staff are available to tackle delays in transfers.

A central 'hub' has been set up as a point of contact for patients before they are assigned a coordinator, the inquest heard.

Mr Farrow concluded that Miss St Louis died as a result of a road traffic collision, 'having taken alcohol and controlled drugs'.

He said she had suffered with anxiety from a young age, which she 'regulated' with cannabis and 'binge drinking' alcohol.

A drug and alcohol service referral was 'considered' in September 2020, Mr Farrow said, but there was 'insufficient' evidence that it was acted upon.

The coroner said Miss St Louis had earlier thoughts of self-harm, but said there was no evidence to suggest she was in that frame of mind at the time of her death - and that she was not likely to have been deliberately trying to put herself in danger by sitting in the road.

He described a lack of staff, especially care coordinators, in the mental health service as 'unsatisfactory'.

Mr Farrow said: 'That person [a care coordinator] may have been able to address her complex needs around alcohol and drugs and may have been a source of support for her.

'But I can't say a care coordinator would have stopped her from drinking as she did on November 28.'

Miss St Louis' aunt, Tanya Roxbrough, said her niece was a 'lovely girl' who 'loved her family' and was 'quite a character'. 

She added that Miss St Louis had struggled during the first Covid lockdown, which had a knock-on effect on her mental health.