The suicide of a 13-year-old girl might have been prevented if the local health board had provided better support, a sheriff has ruled.
Sophie Parkinson took her own life at her home in Dundee on March 1, 2014.
A fatal accident inquiry into her death heard Miss Parkinson had experienced suicidal thoughts, had made previous suicide attempts and had also self-harmed.
She also viewed inappropriate content on her phone and had been in contact with older men online before her death.
Sheriff Lorna Drummond ruled that if a number of precautions had been taken by NHS Tayside Child and Adolescent Mental Health Services (CAMHS), they “might realistically have resulted in the death being avoided”.
These included CAMHS using a structured risk assessment and “accordingly correctly categorising Miss Parkinson’s suicide risk”.
Other precautions would have been CAMHS implementing a care plan which included a greater level of engagement with Miss Parkinson and consideration of a more intensive level of community care, as well as allowing her family more input into her care.
In her 100-page report, the sheriff also found the CAMHS system of patient risk assessment and risk management was “defective” and among the factors which contributed to the death.
She also said the CAMHS system of communicating and recording patient care with patients, their parents and third parties was “defective”.
During the inquiry, Miss Parkinson’s mother Ruth Moss described her daughter as “loving, kind, sensitive and very intelligent, way above her years”.
Despite her daughter’s self-harming, suicidal thoughts and previous suicide attempts, the teenager’s mother “was of the view that the clinicians were not taking Miss Parkinson’s risks seriously and did not properly assess the suicide risk she posed”, the sheriff said.
The sheriff has made three recommendations, including that CAMHS should ensure out-of-hours support for its patients and that the patients and their carers know who to contact for this.
She said CAMHS should provide written information to patients and their carers explaining the organisational structure and the role of clinicians, and should investigate the viability of “safe space” beds as currently provided to CAMHS patients of the Lancashire and South Cumbria NHS Foundation Trust.
The inquiry took place over six days in August and was held virtually due to coronavirus.
Professor Peter Stonebridge, NHS Tayside medical director said: “On behalf of NHS Tayside, I wish to say that our thoughts are with Sophie’s family and friends at this time.
“We would like to extend our deepest sympathies to them again today and are sorry for their ongoing distress.
“We will now be carefully considering Sheriff Drummond’s detailed determination.
“There are three recommendations for NHS Tayside which the child and adolescent mental health team will work to fully address.
“There have also been a number of internal and external reviews; these have resulted in changes to treatment plans and pathways in our child and adolescent mental health service.
“This includes the use of a multi-agency care plan which we call ‘the team around the child plan’, which includes a structured risk assessment.
“Everyone involved in a child or young person’s care and treatment can access this single, individualised plan.
“NHS Tayside remains absolutely committed to improving mental health services for children and young people across the area.”