A ''tortured' woman was found drowned in a canal in Trafford a decade after her father died in the same way, an inquest heard.
The body of Susan McGowan, 57, was discovered in the Bridgewater Canal in Altrincham last June.
Counsellor Ms McGowan was battling severe mental health issues at the time and was on a waiting list for a hospital bed, an inquest into her death was told.
Her family said the "system had failed her" as a Coroner ruled she took her own life.
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Bosses at the trust who were responsible for her care said that though the Coroner found that the care and treatment provided to her did not contribute towards her death, "there are always things to be learned from tragic incidents such as this."
Ms McGowan's body was discovered in a 'remote' stretch of the canal off Seamon's Road in the Oldfield Brow area of Altrincham, by a jogger early on Tuesday, June 22 last year.
Emergency services were scrambled and she was declared dead at the scene just after 6:40am.
She was not identified until the following day after her family alerted police that they feared it could be her as they had been unable to contact her.
It marked a double tragedy for the family following the death of Ms McGowan's father, the inquest heard.
"Unfortunately my father did exactly what Susan did 10 years before, after an argument with Susan" Susan's sister Amanda McGowan said whilst giving evidence.
"I don't know what her thinking was. Whether she wanted to follow in his footsteps or she wanted to be with him and that was the way she thought she could be with him. I don't know."
Ms McGowan's father was not named in the hearing and no further details were given.
Ms McGowan, who was diagnosed with Bipolar Disorder 25 years earlier, had suffered with mental health problems "all of her adult life" her sister said. However, she chose not to take any medication.
She was referred to her local community mental health team at the end of 2020 the hearing was told.
And in the weeks before her sister's death, Susan was "completely psychotic, paranoid and tortured by her thoughts" Amanda McGowan said.
She had "absolutely no quality of life" and was "completely and utterly consumed in a world that wasn't real" she added.
On June 18, four days before her death, she admitted to having had suicidal thoughts and handed over to a social worker a mug containing a number of crushed tablets the inquest heard.
However, she said she was now willing to go into hospital for treatment, which according to her sister was "the first time in her life she had done that."
She was added to a waiting list for a bed and she was referred to the home-based treatment team with planned daily contact until one became available.
However, two days later, she told her care co-coordinator she now didn't want to be seen by that team and also 'withdrew' her consent to go to hospital.
Susan's family said they believed she should have been assessed under the mental health act, and sectioned at this point for her own protection.
"She wasn't someone who had been hiding under the bed in the pandemic" Amanda McGowan told the hearing.
"She was always on the phone asking for help.
"The system has failed my sister. That's totally contradictory to us, she was waiting for a bed, she had the intention to kill herself, she was a serious risk, and the system has completely failed to safeguard my sister."
"Someone should have taken control of the situation and sectioned Susan" she later added.
However consultant psychiatrist Dr Luis Rojo, then working for Trafford South Community Mental Health Team (CMHT) who were caring for Ms McGowan, said in his opinion she "wasn't detainable" under the act, and to try to do so may have damaged the trust between her and her clinicians 'irreparably.'
She died three days before a scheduled outpatient appointment with Dr Rojo which the inquest heard she had said she intended to attend.
The manager of the Trafford South CMHT Linda Skinnion said a review was carried out following Ms McGowan's death and a number of "learning points" were identified and actioned.
Following the discovery of her body, Ms McGowan's bicycle was found on nearby Seamon's Road, the inquest at South Manchester Coroner's Court in Stockport on Tuesday (February 15) heard.
Police Coroner's Office Colin Price said there was no CCTV and no witnesses to her entering the water so they were unable to say how she ended up there.
However, he said there was no obvious injury or trauma and no evidence of any third-party involvement or criminality.
A post-mortem concluded her cause of death was drowning with opiate toxicity said to be a contributing factor.
Toxicology analysis found the level of the drug in her system was likely to have caused some 'incoordination' and may have affected her ability to swim.
Summing up the case, Assistant Coroner Christopher Murray said the death of Ms McGowan;s father was one of a "number of troublesome issues in her very complicated history."
He said: "Having considered all the evidence...I am of the opinion on the balance of probabilities, in absence of any third party involvement or criminality, or attempt to escape the water, I am going to make a finding of suicide as the coronial conclusion."
He said there had been an "instant" investigation by the trust and that in the circumstances he did not believe there was any need for him to complete a prevention of future deaths report.
"It is clear from the evidence that Susan's family deeply cared for," he said adding: "it is just so tragic that matters ended in the way they did."
In a statement issued following the hearing, Gill Green, Chief Nurse at the Greater Manchester Mental Health NHS Foundation Trust (GMMH) which provides community mental health services in Trafford said: "On behalf of the Trust, I express our deepest condolences to Susan’s family and all who cared for her.
“Though the Coroner found that the care and treatment provided to Susan by GMMH did not contribute towards her death, there are always things to be learned from tragic incidents such as this.
“The Trust undertook a thorough review into the circumstances leading up to the incident, which found that there were improvements to be made in the areas of risk management, and family and carer engagement.
"A thorough action plan to address this was developed – which focused on updating our policies and procedures and delivering comprehensive training to staff. All actions have now been completed.
“We understand this comes too late for Susan, and our thoughts are with everyone affected at this sad time.”
