The heartbroken family of a depressed senior social worker who took her own life have told of their desperate attempts to get the help she needed.

A coroner ruled that Annie Peel, 66, a social worker in Cumbria for 28 years, took her own life after falling into a severe depression triggered by changes at work and issues which left her deeply unhappy with how she was managed.

Miss Peel’s adult children told a three-day inquest that the county’s mental health services failed to adequately safeguard her.

Coroner Dr Nicholas Shaw said health professionals missed a key opportunity to protect Miss Peel two days before she died when her family – alarmed that Miss Peel had searched for a chemical to poison herself at her Waverton home, near Wigton – pleaded for an emergency assessment.

If done, she could have been hospitalised against her will.

Cumbria County Council GMB union convenor Ken McDonald told how Miss Peel told him that an informal action plan was drawn up to address “competency issues” with her work – but she saw this as an attack on her credibility.

She wanted to move to a lower-graded job.

“Annie told me the reason she was doing this was because she couldn’t tolerate the pressure she felt she was being put under and that she didn’t want to continue with [her] team manager role,” said Mr McDonald.

In December 2016, she told him it was imperative she get out of her job as she felt overwhelmed by the scrutiny she was under. “Annie was quite emotional at this point and had tears in her eyes,” said Mr McDonald.

A few months later, he met her again at her daughter’s house in Carlisle. “I was struck by how frail and emotionally agitated Annie was,” he said.

Miss Peel's boss was Carlisle and Eden Service Manager Louise Kitcher.

In a statement, she outlined dealing with a complaint about Miss Peel's management, and concerns raised about her in 2016. In August an audit also highlighted concerns about Miss Peel’s oversight of some children’s cases.

Miss Peel welcomed the feedback but was upset, said Ms Kitcher, adding that was a hard-working team member, committed to keeping children safe and well.

She added: "She had a great sense of humour that could lift spirits and colleagues and families alike held Annie in their affection. The shock of Annie's untimely death has been felt in the Carlisle teams but also across the county."

The inquest heard an extensive medical background.

Miss Peel suffered mental health problems in the past – a stress-related illness in 2004; and then again in 2008, when she had anxiety and depression.

In early 2017, her work-related stress intensified to the point where she felt unable to continue her management role.

In a GP’s consultation, she was distressed, tearful and negative, though her family were extremely supportive. Miss Peel was voluntarily admitted to Carlisle’s Carleton Clinic on March 16, but left – against medical advice – after a day.

Consultant Dr Muhammad Mustaq said she did not like her new manager and was affected also by increased work pressure and two complaints against her.

Despite her high risk of suicide or self-harm, Dr Mustaq respected her wish to not be hospitalised, provided she had intensive support and treatment at home.

Miss Peel’s son Jasper Kirkman said the medical professionals, by declining to section his mother, transferred the risks of her illness to the family. Even after a suicide attempt two days before she died, the family’s request for her to be assessed for possible Mental Health Act detention was declined.

“There was a pattern of transferring the risk to the family over the previous week,” said Mr Kirkman. Bonnie Kirkman said of her request for a Mental Health Act Assessment on March 20: “That was my desperate last attempt to get help.”

A compulsory hospital admission may have saved her mum, she said.

Both Jasper and Bonnie Kirkman said they were not trained in caring for somebody at risk of suicide. Jasper Kirkman added: “Unfortunately, our mum didn’t get the service which safeguarded her.”

Given the severity of Miss Peel’s illness, a Mental Health Act Assessment should have been done, said Dr Shaw.

A Cumbria Partnership NHS Trust spokeswoman said of its probe into the tragedy: “Although the investigation did show areas of good practice, it highlighted a number of improvements which could be made, all of which have now been implemented.

“We have ensured lessons have been learned by Miss Peel’s sad death and we apologise to the family that some processes were not in place that would have ensured the high quality of care which we strive to provide for all our patients.”

The County Council’s People Directorate boss John Macilwraith said: “These were a very difficult set of circumstances but the council has an absolute duty to deal appropriately with employee performance if it does not meet the standards that are required, particularly where vulnerable children are concerned.

“The council and Annie’s manager tried hard to support her, making repeated offers of referrals to our Employee Well-being Service among other measures.”