The death of a mother-of-two who stepped before a train could have been prevented by mental health staff, a coroner has ruled.

Petra Goto, 40, of Orchard Way, Shirley, died at Kent House rail station in April 21 last year after South London and Maudsley NHS Trust failed to monitor her depression and Schizophrenia or respond to desperate calls for help from her family.

Coroner Selena Lynch said staff shortages and individual failings had contributed to the volunteer charity worker's death, which sparked an internal investigation by the trust.

An inquest at South London Coroner's Court on Wednesday heard Miss Goto, who lived with her twin teenage sons, suffered a relapse in her mental health problems in the weeks before she died but had not been seen by nurses or doctors since September. 

Her sister Eunice told the court she had repeatedly tried to contact the trust's community psychiatric team, which had cared for Miss Goto as an outpatient since 2011, to urge them to intervene but her calls had not been returned.

She said: "She was getting quite agitated and paranoid. The children started saying that mum was out of hand. She was going to into their rooms and talking to them all night so they couldn't sleep before they went to school."

The court heard Eunice left several messages for her sister's care co-ordinator, but called paramedics - who attended but could not help - out of desperation when she did not hear back.

The co-ordinator called Miss Goto's sister on April 18 and told her a review of her care would be carried out, but three days later the Zimbabwean national walked from her home, telling her sons "the next time you see me I will be dead". She died of multiple injuries after being hit by the train at 60mph. 

Dr Avirup Gupta, Miss Goto's psychiatrist, said she had been deemed a low suicide risk, adding the fact she had not picked up a prescription for her anti-psychotic medication since November would not necessarily be grounds for fast-tracked care review.

But he admitted that "would have changed" had he received information from Miss Goto's sister that she was suffering paranoid delusions.

The court also heard Miss Goto was last seen by the trust on September 6 and her care co-ordinator, with whom she had a good relationship, left her role in November and was not replaced until January. 

Patricia Clark, manager of the East Croydon Recovering Service Team, based in Tamworth Road, attributed the delay to the system of applying for funding for temporary cover. 

She said she was "really concerned" that Miss Goto's sisters messages had never been picked up but said "we simply could not find any" evidence of them. 

Mrs Lynch said: "You could be forgiven for thinking that she was being largely ignored."

The coroner, recording a narrative conclusion, ruled there were "some causative failures" by the trust that had contributed to Miss Goto's death. She said: "There were failures to monitor this lady and especially to react appropriately when a crisis was imminent."

She added: "While no one can be sure, I think it's probable that an earlier and more robust reaction could have prevented Miss Goto's death."

The coroner said there the failures were "not systemic but more an issue of individuals and resources, and that is particularly an issue that is outside my remit."

She added was satisfied that recommendations made by the independent expert that carried out the trust's review were being acted upon.

The recommendations included clarifying the role of the care co-ordinator and improving the system for monitoring if a patient is collecting prescribed drugs.

A spokesman for the trust said: "The trust offers its sincere condolences to the family and friends of Petra Goto. 

"A full internal investigation was carried out following Petra’s death and recommendations were made in relation to local practice and procedures. An action plan has been implemented and will soon be complete. 

"The coroner found no systematic failings in the care we provided and expressed confidence in the trust’s investigation and action plan."