A London teenager hugged her mother and said she believed her medication needed to be increased hours before she took her own life.
Emily Burns, 18, death followed “a lack of safety planning” when she was discharged from adolescent mental health services in north east London, an inquest into her death was told.
Now her parents have spoken out about how they feel their daughter was let down “when Emily needed the help the most”.
It comes after a coroner heard evidence of failings in Emily’s care but did not find, on the balance of probabilities, that any aspect of care directly contributed to the teenager’s death.
The aspiring costume designer, from Waltham Forest, was taken care of by CAMHS (child and adoloscent mental health service), run by North East London NHS Foundation Trust, and had been diagnosed with anxiety, depression and anorexia, for which she had received treatment.
She started taking antidepressants in February 2022 and had been referred for psychotherapy in April 2022.
But she “slipped through the net” and, following a lengthy delay, received a short course of therapy that was inadequate for her needs in January 2023, a coroner said.
When the sixth-form student turned 18 a decision was made to transfer Emily’s care to a GP.
But she had not been reviewed by a senior doctor and her parents were not involved in planning her discharge, Law firm Irwin Mitchell said.
On the day she was transferred, the teenager took an overdose of medication and was admitted to hospital.
Emily was transferred to an adult home treatment team following the overdose, and the student - alongside her family - repeatedly asked for her medication to be reviewed and for her to receive psychological therapy.
A plan was put in place for her to restart her antidepressants, to be referred for psychotherapy and to receive regular home visits from the mental health staff.
She received an initial assessment on May 5 2023, but this was not from a fully qualified therapist, an inquest heard.
She took her own life four days later.
Hours before she died, Emily had hugged her mum before school and said she thought her medication was not working and needed to be increased.
Emily was beautiful inside and out
Paying tribute to their daughter, Emily’s parents Renata and Quinton said in a statement: “Emily was a very talented person. She was passionate about music, she played cello and electric guitar.
“She would spend hours creating her art at home. Emily loved nature, long walks in the forest and was also passionate about horse riding.
“Emily wanted to be a costume designer for the theatre and film industry. She was a very hard-working person always dedicated to her work and was about to start university.
“Emily was beautiful inside and out but sadly really struggled with her mental health. We tried everything we could to get her the care she deserved but she tragically took her own life leaving us behind in agony, pain and despair.
“Our family and our lives have been broken into pieces and we now feel an emptiness which cannot be rebuilt.
“Emily had so much promise and all the hopes, plans and dreams she had will never get to be fulfilled.
“We’ve experienced the greatest loss that a mum and dad would ever have - the loss of a child. The circumstances around Emily’s death will affect us for the rest of our lives.
“We’ll always be upset and angry at how when Emily needed the help the most, we feel she was let down.”
Concluding an inquest into her death coroner Nadia Persaud said she had “heard evidence relating to failures in the care provided to Emily” but on the balance of probabilities that any aspect of care directly contributed to the teenager’s death.
During the inquest, the coroner said “there was a lack of safety planning” on Emily’s discharge from CAMHS and “a poor transition” from CAMHS to adult mental health services.
She also described the diagnostic work of the home treatment team as “inadequate”.
Ms Persaud recorded a narrative conclusion that Emily took her life whilst suffering from a partially treated mental health disorder.
Charlotte Stawiska, the Irwin Mitchell lawyer who represented Emily’s family at the inquest, described how the “incredibly tragic case” was one of a number the firm had seen where “vulnerable young people with mental health difficulties haven’t received the care they deserve”.
She added: “Some of the evidence heard during the inquest is extremely worrying. It’s now vital that lessons are learned to improve patient safety for others and stop young and vulnerable teenagers falling through the cracks between child and adolescent and adult mental health services.”
If you're struggling and need to talk, the Samaritans operate a free helpline open 24/7 on 116 123. Alternatively, you can email jo@samaritans.org or visit their site to find your local branch.
