28/02/2012 14:53 GMT | Updated 28/02/2012 14:54 GMT

Melissa Martin Hughes Death: Hanged Teenager Had 'Woeful Support' Says Coroner

A coroner has criticised the "woeful" mental health support given to an "exceptional" student found hanged.

Melissa Martin Hughes, 18, was found by a passer-by next to a children's playground in a park in Cheltenham, Gloucestershire in April 2010.

The medical director for 2Gether NHS Foundation Trust admitted a "series of failed responses" and "gaps" in the mental health service provided to the talented teenager.

The death of Miss Martin Hughes, who was predicted top grades in her A-levels, was described by her family as a "tragedy".

Her father Donald Hughes has criticised the care given to his daughter, adding that his family were "let down" by the service, the Press Association reported.

The teenager, who experienced "dark episodes", was briefly sectioned before being discharged into the care of her parents following an attempt in August 2009 to throw herself from Beachy Head in East Sussex.

She had travelled there secretly by train the day before the publication of her AS exam results. It turned out she had passed with A*s.

But the Pate's Grammar School pupil was seen just twice following the incident, going seven months without follow-up care because cover was not provided when her psychiatrist went on sick leave and messages from her family were not passed to NHS staff.

The deputy coroner said there appeared to have been a "meltdown" in communication between the crisis team and the primary care assessment and treatment team (PCAT) at the 2Gether trust which provides mental health services in Gloucestershire.

Speaking at her inquest in Gloucester on Tuesday, Dr Paul Winterbottom, medical director of 2Gether, said: "What we saw in this situation 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.

"I do fully accept the breakdown in communication, the transfer of information within the service in this particular instance, and the breakdown in effective communication with Melissa and her family. Recognising the challenges there are in sharing information at times contributed to our not providing the service that we would have wanted to and intended to."

The two-day hearing was told Miss Martin Hughes worried about her appearance after suffering from severe acne since she was 14 and had a history of self-harm.

Deputy 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 from Dr Winterbottom who has openly accepted and admitted 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.

"There was what appears to have been a meltdown in the messaging service between PCAT and the crisis team.

"I did comment it was a rather shambolic situation with regards to the message-taking and transferring which did result in what appears to be a complete remodelling of the system."

Recording a narrative verdict, in which he concluded that Miss Martin Hughes took her own life, Mr Dooley added: "No immediate replacement consultant contact or targeted treatment was made available to her and this constituted a missed opportunity to continue assessment, provide any formal diagnosis or appropriate treatment or indeed give continued care.

"Her last contact with her local support services was on 16th September 2009.

"Despite urgent pleas from her parents for support and guidance over the period of September, October and November of 2009, no adequate response or assistance was forthcoming."

Mr Dooley also pointed out Miss Martin Hughes's death was one of a "cluster" of three involving people under the care of the trust in the spring and summer of 2010.

But Dr Winterbottom insisted there were significant differences between the cases.

The medical director accepted Ms Hughes's family had been "let down", adding that the whole communications system had been changed to avoid the same problems.

In a statement, the teenager's family said: "We are in accord with the coroner's findings and it goes without saying we feel let down.

"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.

"We miss her constantly. We will always be proud of her."