Health professionals failed girl who took her own life, says mother
The mother of a teenage girl who took her own life has criticised the health professionals who "failed" her daughter and said she would never have left her alone if she had been warned she was a suicide risk.
Sandy Legg said 14-year-old Sofia was "failed by the system" and said no parent should have to "beg" for professional help.
Speaking after a coroner recorded a conclusion that Sofia had taken her own life by hanging, Mrs Legg said: "As a family we will forever mourn the loss of our kind, bright, beautiful daughter. Sofia was failed by the system and we, as a family, feel badly let down.
"Tragedies like this have increased dramatically in recent years. Children like Sofia are being failed by the very agencies that have been set up to protect them.
"Something more needs to be done to protect our children, so that other families do not have to experience the pain, devastation and sense of loss that our family is going through.
"No mother should repeatedly beg for professional help for her child and no child in immediate need should be placed on a six-month waiting list.
"We hope that the agencies involved will learn from this and make changes to ensure that young people and families, who rely on the professional expertise of these organisations, are not failed in future."
The inquest in Taunton heard Sofia had been seeking help from the Somerset Partnership NHS Foundation Trust after suffering from low moods, was self-harming and expressing thoughts about taking her own life.
Her mother, father Kevin and elder brother Daniel found her dead when they returned home on the evening of September 20 last year from working as film extras.
It was hours after an argument with another girl at the Kings of Wessex Academy over a boy, which had continued by text message. The inquest heard that this was not a "key trigger" for her death.
"It was a teenage spat and I don't see it as a prolonged bullying episode," Mrs Legg said.
She told the hearing her daughter's behaviour at school had deteriorated and she had made friends with girls she had previously thought were "naughty".
Mrs Legg had taken Sofia to her GP in March 2015 after becoming worried about her low mood and teachers reporting signs of self-harm.
The doctor referred her to child and adolescent mental health services (CAMHS) but they decided she did not meet the criteria for specialist support.
In February 2016, Mrs Legg noticed patches on Sofia's head and suspected she was self-harming by pulling her own hair out.
Four months later Sofia's GP made an "urgent referral" to CAMHS after the teenager confessed she had been having suicidal thoughts.
She was seen twice in July by care co-ordinator Camal Dhillon who told Mrs Legg there was a six-month waiting list for cognitive behaviour therapy.
The inquest heard that Sofia's mood dropped after returning to school for the new academic year and Mrs Dhillon phoned Mrs Legg to see how her daughter was.
The day before Sofia's death Mrs Dhillon had a meeting with her and the teenager told her she had put an item that could have been used for self-harm under her bed.
"Camal told me we needed to secretly take away (the item) from the bed in her room and that I needed to watch her and keep a close eye on her," Mrs Legg said.
"Camal gave us a crisis plan, which included things like talking. There were instructions for Kevin and I to check on her regularly.
"No follow up appointment was made during this meeting but Camal said she would speak to a psychiatrist and review the case to see whether medication was a good option and that she would contact me as soon as she had an answer."
Mrs Legg said that following her daughter's death she had read investigation reports stating that she had been told by Mrs Dhillon to supervise her daughter at all times.
"I was angry with this because this is different from the words used by Camal to me personally which was to watch her and keep a close eye on her," Mrs Legg said.
"This is also different from the crisis plan which says we were to 'check in regularly' on her.
"If constant supervision was necessary then this should have been stated directly to me before I left with Sofia.
"In addition I am angry as I feel Sofia's school should have been informed this was necessary too so they could provide supervision at all times while Sofia was away from home."
Somerset Coroner Tony Williams said Sofia had left an undated handwritten note in "apologetic terms" but said he was satisfied the teenager had intended to take her own life.
He said he would be writing a preventing future deaths' report to the Trust raising his concerns about what he had heard in evidence.