NHS failed Easton's David Hart, 17, before death, parents say
The parents of a Somerset teenager who took his own life have said they felt he was let down by the NHS.
David Hart, 17, from Easton near Wells, had depression and was found dead at home in November last year.
Don and Lynne Hart said they had been kept "in the dark" as confidentiality rules meant doctors were unable to tell them he had attempted suicide before.
An inquest heard that David had twice been referred to mental health services but no follow-up was made.
Recording a narrative verdict at Wells Town Hall, coroner Tony Williams said he would be writing to the appropriate authorities in Somerset.
The inquest was told that at the age of 16, David was referred by a GP to the child and adolescent mental health services but he was not seen and the referral was not followed up.
Then, 18 months later, a second doctor urgently referred him to the adult mental health services but, again, David was not seen and no-one followed it up.
Three weeks later David took his own life, the hearing was told.
His mother Lynne, said: "If the doctor had included us in that knowledge Dave may still be with us today.
"Confidentiality denied us the right to properly care for and protect our child. We were parenting in the dark.
"We feel that the fear of breaking confidentiality is dominating the NHS and young people, particularly those aged 16-17, are being denied the family support they need."
Somerset Partnership NHS Foundation Trust said that, since David's death, it had "extensively reviewed its communications processes and procedures" between its mental health services and GPs.
In a statement, it said: "In particular, the trust has improved its procedures to ensure that patients who do not attend appointments are quickly followed up and personal contact made with them to ensure their safety and well-being."
It said it would provide a comprehensive explanation of the measures it has taken since David's death to reduce such a situation occurring again.
Mr Williams told the hearing he wanted to highlight such issues as patient confidentiality, record keeping and follow-ups after a patient has been discharged.
He said he would also be asking both adult and adolescent mental health services to review their urgent referral procedures.
Last year, David's family released a song that he composed and recorded, to raise money for the Papyrus UK charity that helps people at risk from suicide.