The family of a talented young woman from Leeds who took her own life broke into applause as a coroner announced that he would write to health bosses ensuring they take action to prevent future suicides.
A-level student and waitress Afrika Yearwood, who was 18, injured herself on May 21 2018 but despite immediate resuscitation efforts she died four days later at Leeds General Infirmary.
Senior Coroner Kevin McLoughlin today delivered a narrative verdict at the conclusion a two-day inquest, before which he stated that there had been a "lamentable catalogue of missed opportunities" by various agencies to help the Rodillian Academy sixth-former.
No diagnosis of a mental health condition was established during her treatment and the coroner described her actions as "a reflection of her impulsive nature".
The coroner stressed that he was not critical of any individual clinician, who he said were "striving to help".
After suffering deteriorated mental health in autumn 2017, when she was 17, the straight-A student from Rothwell began private psychotherapy sessions in December.
Following an overdose of tablets in February 2018, she was assessed by Dr Gareth Howel, of Child and Adolescent Mental Health Service CAMHS. She was also prescribed anti-depressants and reviewed periodically by her GP.
She "revealed suicidal thoughts, but not imminent or detailed plans to act upon them" and was deemed to present a low risk of taking her own life, reads the coroner's statement.
As Afrika turned 18 on March 14 that year, "she did not fall neatly in the province" of CAMHS or the Community Mental Health Team, which serves adults.
Mr McLoughlin said: "Informal contact had been made in February 2018 with the CAMH's Transitions Team which seeks to cater for young people in the months before and after their eighteenth birthday, but this did not result in more intensive psychiatric input in the months from March 2018 onwards."
A nurse referred her to the Community Mental Health Team on May 17 for longer-term support, but Afrika and her family were unaware of this action until after her death.
The inquest previously heard evidence from Afrika's mother, Beverley Yearwood, who told the court her daughter had been "ping-ponged" around by agencies.
"There was more time spent on emails between services than there was on Afrika," she said.
Mr McLoughlin told the hearing that "I cannot say on the balance of probabilities" that more intensive therapy would have helped Afrika, who had attended 17 hour-long cognitive behaviour therapy sessions with Michelle Pittam.
When Dr Howel assessed Afrika during their 45-minute appointment, he deemed her at low risk, but said that "in retrospect" he would have increased that to medium risk.
He told the inquest: "Afrika told me she didn't have any thoughts to harm herself or of suicide at that time."
The inquest was told that health agencies accepted that they needed to be clearer when communicating their referrals, and that various actions were being put in place to address concerns.
Mr McLoughlin said he would send a 'regulation 28' report, also known as Preventing Future Deaths report, to Leeds Community Healthcare NHS Trust and Leeds and York Partnership NHS Foundation Trust.
The extended family of Afrika present in the courtroom broke out into applause at his announcement.
Mr McLoughlin concluded that Afrika died of a hypoxic brain injury and hanging at 3.16am on Mary 25 2018.