An Orpington woman jumped in front of a train at Petts Wood station after being under the care of Oxleas NHS Foundation Trust, an inquest has heard.
Croydon Coroner's Court heard how Wendy Taylor, 60, of Gload Crescent, died at 10.56am on April 23 when she was hit by a train travelling from Charing Cross to Tunbridge.
Her daughter Carly Taylor, who lives in Lisbon, Portugal, told the court her mother was "the most depressed I have ever seen her" two weeks before her death - the last time she saw her.
The 34-year-old said: "I came to visit her for her 60th birthday. She was not well at all.
"I said to her please promise me you won't do anything stupid. She'd promised me before but this time she couldn't look me in the eye and say it.
"We sent texts to each other and e-mailed every day.
"She'd written to me to say she'd been to her good friends that day for lunch. I later found out she didn't go."
Wendy had been diagnosed with anxiety in June last year and suffered from frequent depressive episodes.
She was an inpatient at Green Parks House mental health centre, run by Oxleas NHS Foundation Trust, three times in the year before her death.
Coroner Selena Lynch: "The conclusion is she killed herself. I think she made that decision because of this severe and enduring problem that she had."
Carly told the inquest she felt let down by the standard of healthcare her mother received.
She said: "For the whole journey through this I never knew what was happening. I never knew of a care plan.
"I expressed time and again my concern that she needs help.
"Martin Smythe was the only person who listened to me, who was compassionate. With him I felt heard and supported."
The court heard how Mr Smythe, Wendy's care co-ordinator, took indefinite sick leave in January, and his role was only replaced by Oxleas a week before her death.
Speaking at the inquest, Dr Keith Miller - Wendy's psychologist - said he assessed her as an 'amber' - medium - suicide risk on April 10.
The inquest heard how he expressed concerns to Jill Mills, a psychological therapist.
Ms Mills told the court she was unaware of Wendy's suicidal tendencies when she relayed information to line manager Caroline Shannon.
A spokeswoman for Oxleas said: "When clinicians have to take sick leave, each patient is transferred to other appropriately qualified clinicians who will continue with their agreed treatment plan.
"In this instance, Ms Taylor's care coordinator went on sick leave but Ms Taylor continued regularly to see her psychologist.
"As soon as he felt she needed a greater level of care, additional appropriate support was arranged for her.
"The new care coordinator made contact with Ms Taylor and at that point, there were no indications that she may pose such a risk to herself."
Carly Taylor said her mother, who was a former administrator with the London Probation Service, was a "smiling and beautiful lady" who was "loved by many people".
She told News Shopper: "My mother was loved by so many people. She had a positive impact on so many people’s lives.
"She was a smiling and beautiful lady who was always there to support her friends and especially myself when needed.
"She was a person who was everyone's friend - anyone with a problem, she was always able to help them.
"Everyone remembers her laugh, her brilliant sense of humour.
"She cared for so many people, but I feel the time she needed help she couldn't get it."
- VIDEO: Blackheath roundabout attack caught on camera
- The dress that broke the internet: Orpington shop enjoys stampede of sales
- Woman jailed for four years after tricking man into using his toilet in New Cross
- FUNNY FRUIT: As first 2015 crop appears, will we get another penis or foot-shaped strawberry?
- PubSpy reviews The Rising Sun, Lewisham