Sophie Ecclestone's mother had been asking for help for her daughter since 2018, an inquest into her death was told this week.
After two days hearing evidence at the inquest at the Shirehall in Shrewsbury, coroner for Shropshire and Telford, Mr John Ellery, adjourned on Tuesday to deliberate on his conclusion.
He said he would have to consider whether Sophie's death was suicide or misadventure - an act of self-harm that went tragically wrong. Or he said he may give a narrative verdict.
The coroner said Sophie, who was described as impulsive, had left no note and previous overdoses had not been seen as attempts to take her life.
He said he would also be considering whether anything could have been done to prevent her death.
The inquest heard that Sophie, who usually lived with her mother Leanne, at The Saplings, Telford, had been staying with her grandmother two days a week.
On February 17, 2022, her grandmother, Lynn Haycock, found Sophie in the house. Neighbours went to her help and carried out CPR until paramedics arrived. Sophie was airlifted to the Royal Stoke University Hospital but she died four days later.
Mrs Haycock, who said Sophie had seemed happier than she had done for some time, said she would never get over what had happened.
The inquest was told that Sophie had been awaiting an assessment for autism through the Midlands Partnership NHS Foundation Trust, which specialises in mental health.
She had both face-to-face and telephone appointments with staff from the foundation trust and it was suggested that she seek help from the trust's BeeU service and also self-refer to Beam, an emotional health and wellbeing service for young people who are registered with a GP in Shropshire, and Telford & Wrekin.
In December 2021 she was taken to the Princess Royal Hospital having taken an overdose, with a second similar act in January and third on February 5, 2022.
She was put on the Midlands Partnership crisis list.
The coroner was told that her mother had asked if Sophie could be helped with medication or rehabilitation away from home but neither were thought appropriate.
After Sophie told a member of the mental health team that she had no intention of ending her life it was decided she was low risk and she was discharged from the crisis team.
Giving evidence to the inquest Sharon Conlon, head of safeguarding at the Midlands Partnership Foundation Trust, said that an internal investigation into the teenager's death had shown that she should have been referred to the CORE CAMHS support service for young people.
This would have given her a named member of staff working with her.
What is being done now?
The trust that was providing care for Sophie Ecclestone before her death has said it is implementing improvements identified after a review of that care.
Extra staff are being recruited including a clinical nurse specialist who will work from the Accident and Emergency Department at the Princess Royal Hospital in Telford.
The Midlands Partnership NHS Foundation Trust works with The Children’s Society, Kooth, and Healios to deliver emotional health and wellbeing services across Shropshire, Telford and Wrekin.
Speaking after the two days of evidence at the inquest into the death of the 13-year old, Dr Abid Khan, Medical Director of Midlands Partnership NHS Foundation Trust, said: “It is with great sadness that I send my sincerest condolences to Sophie’s family at this difficult time.
“Following Sophie’s tragic death a detailed review took place to review the care which Sophie and her family received from the Trust.
“This process identified a number of improvements.
“Implementing these improvements is an organisational priority and we are continuing to work with the BeeU service to ensure we can provide the highest quality mental health care to children, young people and their families within Shropshire, Telford & Wrekin.”
The inquest heard evidence from Liam Laughton who is the children, young people and families services manager.
He said BeeU’s Children and Young People’s Crisis Resolution and Home Treatment team was working with colleagues in MPFT Mental Health Liaison Service, Shropshire and Telford Hospitals Trust (SaTH), and Children’s Services Local Authorities, to ensure that it provided a safe and effective service model.
“We will shortly be recruiting a clinical nurse specialist to work from the Accident and Emergency Department at Princess Royal Hospital, working between the SaTH Emergency Department, MPFT BeeU Crisis Team, and MPFT Mental Health Liaison Team, to provide timely access to Mental Health Liaison within A&E.”
The person should be in place in September.
He added extra mandatory training had been put in place and the Crisis Team have an established process for daily handovers.
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