Kendal hanged teenager 'failed' by services
A review into the death of a 15-year-old has found failings including a lack of appreciation of the "inner world of teenager" among health professionals.
"High-achieving" Helena Farrell, from Kendal, hanged herself at a Cumbria beauty spot in January 2013.
She had earlier reported a series of problems to a school nurse, but had not been seen by any specialists.
Cumbria Partnership NHS Foundation Trust said significant improvements had now been made to the service.
Miss Farrell was said to be academically very able, and gifted in sports and music, but an inquest was also told that she had taken an overdose, self-harmed, and written letters of farewell to friends and relatives.
A day before she died she was assessed by a social worker at Cumbria's Children and Adolescent Mental Health Service (CAMHS) as posing no imminent risk to herself.
The coroner ruled that her death was a consequence of her own actions, although her intention was not beyond reasonable doubt.
A serious case review by Cumbria Local Safeguarding Children Board identified a number of failings.
These included a "lack of knowledge among a range of professionals" about the evidence for high-risk indicators for teenage suicide, leaving them "ill-equipped" to recognise the signs and respond accordingly.
There was also a "lack of appreciation of the "'inner world of teenagers".
Sara Munro, from Cumbria Partnership NHS Foundation Trust, said: "The serious case review found that the circumstances leading up to her death were very complex, and this led to her level of risk being very difficult to fully assess.
"There was an unacceptable delay in her being seen by the CAMHS service and we have made significant improvements to that service.
"This includes the appointment of a new clinical director, four new consultant psychiatrists, an introduction of the out-of-hours services, and a new senior team for the service.
"These changes have been independently assessed to be working well."