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Melissa Martin-Hughes had received no psychiatric help for seven months when she was found hanged, despite pleas
A coroner has criticised the "woeful" failure of an NHS mental health trust to support a talented 18-year-old student who hanged herself from a tree in a park.
Melissa Martin-Hughes began to receive help after travelling to Beachy Head in East Sussex apparently intending to kill herself, but after two initial appointments the psychiatrist who saw her went on leave and nobody took over her case.
When she was found hanged in Pitville Park, Cheltenham, Melissa had not been seen by health professionals for seven months, though her parents had appealed for help.
The deputy Gloucestershire coroner, David Dooley, said: "In my opinion this reflects a woeful picture of a lack of available support for Melissa during the six to eight months prior to her death following the Beachy Head incident.
"We have heard there was a series of failed responses and miscommunications and this has led to a failure in delivering the service intended for Melissa.
"There was no continuity as such and overall this lack of continuity and contact with any designated individual led to a fragmented service for Melissa."
The deputy coroner said there appeared to have been a "meltdown" in communication at the 2gether NHS foundation trust in Gloucestershire between the crisis team and the primary care and assessment team.
Recording a narrative verdict in which he concluded that Melissa took her own life, Dooley said that her last contact with the trust had been in September 2009. Despite "urgent pleas from her parents for support and guidance" there was no "adequate response or assistance", he said.
The inquest in Gloucester heard that Melissa had experienced "dark episodes" since she was 14 when she began to suffer from acne on her face and upper body. She was prescribed drugs that can cause depression as a side-effect, the inquest heard.
Melissa began to self-harm and was found by police "crying and smelling of alcohol" at Beachy Head in August 2009. She was twice visited by a consultant psychiatrist, Guy Undrill, before he went off sick.
The teenager, a high-flying student at Pate's grammar school in her hometown of Cheltenham, was found dead by a mother with a toddler in April 2010.
Dr Paul Winterbottom, medical director of the trust, admitted a number of failures. He said: "What we saw was a series of failed responses, administrative failure, a failure of the referral to be progressed in the way that was expected and planned, and that this led to Melissa not getting the service that was therapeutically orientated and that had been intended." He also accepted there was a "breakdown in communication" within the trust, adding: "I think there was a gap in the service provided to Melissa." However he insisted the communications system had since been changed to avoid similar problems happening again.
The coroner pointed out to Winterbottom that Melissa's suicide was one of a "cluster" of three involving people under the care of the trust in the spring and summer of 2010. Winterbottom insisted there were significant differences between Melissa's case and the other two.
After the verdict Melissa's family released a statement in which they said they felt let down. The statement continued: "Melissa's untimely death is a terrible tragedy, the pain of which will not easily fade.
"Melissa touched so many lives, those who knew her speak of her support and bravery, her creativity, humour and her lively mind. Melissa was a complex, beautiful daughter who brought great joy to us all. We miss her constantly.
"We will always be proud of her."
The 2gether NHS trust said after Melissa's death there was a "full investigation" and a "number of shortcomings" were identified. The trust said: "Our responsibility is to ensure that other people do not have the same experience."