The parents of a student found hanged at her university halls have claimed she was failed by mental health services.
Ceara Thacker, from Bradford, was found dead at her University of Liverpool accommodation in May 2018.
The 19-year-old’s parents said she had fallen “through the cracks” between different services, who failed to communicate with each other.
Area coroner Anita Bhardwaj recorded Ms Thacker’s death as suicide.
She described a delay of two months between Ms Thacker referring herself to the university’s mental health advisers in February, and being given an appointment in April, as “unacceptable”.
The inquest in Liverpool also heard Ms Thacker’s family had not been informed about a previous suicide attempt three months before her death.
Her father Iain, 56, said: “Sadly, when her mental health began to decline she found herself falling through the cracks, with mental health services, her GP and different departments within the university failing to communicate with each other to ensure that she was provided with the support that she desperately needed.
“One crucial source of support could have come from us, her family.
“For as long as I live I will never understand why no-one at the university picked up the phone to us in February 2018 and told us that our 19-year-old daughter was in hospital after taking an overdose.”
The inquest heard Ms Thacker, who was studying philosophy, had struggled with mental health problems throughout her teenage years.
“We had cared for Ceara and helped her through her struggles with mental illness since she was 13,” Mr Thacker said.
“We thought she was stable and managing her mental health well. Eight months after coming to the University of Liverpool she was dead.”
He added: “If we had known how Ceara was suffering we could have, and would have, made a difference.”
Mr Thacker said it was “essential” universities communicated “effectively with healthcare services and, where appropriate, with families to ensure they are kept safe”.
Ms Thacker’s mother Lorraine Dalton-Thacker, 51, said: “At every turn, she was failed.
“I can’t imagine how frightening that must have been for her.
“She should not have had to face this and it breaks our hearts that she did.
“We don’t want any other family to go through this pain.”
Ms Bhardwaj said she would make a report for the prevention of future deaths to the NHS.
She will recommend the issue of parental involvement, with consent, is included in mental health assessments.
The coroner said there was no record of discussions between medical professionals and Ms Thacker about contacting her family.
“It would have been helpful to have those discussions, so if Ceara wanted additional support from her family that could have been facilitated,” she added.
However, it remained “difficult and unclear” whether Ms Thacker “would have had a different outcome had she had additional mental health appointments, been given an urgent appointment and had family involvement”, the coroner said.
The court heard the two-month delay in getting a mental health appointment was caused by “exceptional circumstances” including strike action, staff sickness and training days.
BBC education editor Branwen Jeffreys
For several years universities have been struggling to cope with a sharp increase in students seeking help for mental health issues.
Suicide among university students is rare; it is estimated by the Office for National Statistics at 4.7 deaths per 100,000 students, but each loss is felt deeply by families and they are pressing for change.
Spending on support on campus has increased. Ten universities have received national funding to try new approaches. As a result the University of Liverpool is leading a project on how to work better with the NHS.
The University of Bristol asks every student when they register to give permission for their family to be contacted. Last year 94% signed up for the mental health alerts to parents.
This is a change that Iain Thacker wants widely adopted.
Liverpool has chosen a different approach; asking students if they want family informed only when they are seeking help.
Students are young adults and have a right to confidentiality and, as yet, there is no consensus across universities about how to respect that and manage risk.
Gavin Brown, Liverpool University’s pro-vice-chancellor for education, said: “We have conducted a thorough review of the support Ceara was offered and, as a result of this and our ongoing review of how these services work, we have instigated a number of improvements to mental health support services.”
Dr Paul Redmond, Director of Student Experience added that the university had introduced a rapid access appointment system since the student’s death.
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