Emily Burns, 18, took her own life on 9th May 2023. The teenager, who suffered from mental health problems and anorexia, had asked for her medication to be increased the morning before she committed suicide, reports Sebastian Mann, Local Democracy Reporter

Note: This article contains passages some may find distressing

An 18-year-old mental health patient told her mother her medication needed to be increased the morning before she committed suicide, an inquest heard.

Emily Burns, from Waltham Forest, took her own life on 9th May 2023. She had earlier been diagnosed with anxiety, depression, and anorexia nervosa.

She had been under the care of child and adolescent mental health services (CAMHS), run by North East London NHS Foundation Trust (NELFT).

The trust oversees healthcare provision across Barking & Dagenham, Havering, Redbridge, and Waltham Forest.

A spokesperson for the trust said it had been “working hard” to improve its medical reviews for patients and had implemented new methods for assessing risks.

The sixth-form student and aspiring costume designer was transferred to a GP after she turned 18, but was not reviewed by a senior doctor.

The same day she was transferred, Emily took an overdose of medication and was admitted to hospital. She was then transferred to an adult home treatment team.

Coroner Nadia Persaud concluded that “there was a lack of safety planning” on Emily’s discharge from CAMHS and “a poor transition” from CAMHS to adult mental health services.

The diagnostic work of the home treatment team was also “inadequate,” the coroner added.

Her family had repeatedly asked for a review of her medication and for psychological therapy, the inquest was told.

During a medical review in March 2023, she said her medication was not working and a plan was put in place for her to restart her antidepressants, which she had been prescribed in 2022.

The teenager was also referred for psychotherapy and would receive regular home visits from the mental health staff.

She received an initial assessment on 5th May, but this was not from a fully qualified therapist, the inquest was told.

Four days later, she hugged her mum before school and said she felt her medication needed to be increased as it was not working. She took her life that afternoon, the inquest heard.

The coroner recorded a narrative conclusion she killed herself while suffering from a partially treated mental health disorder.

She said she heard evidence “relating to failings in the care provided to Emily,” but did not find, on the balance of probabilities, any aspect of care directly contributed to her death.

Charlotte Stawiska, a negligence lawyer with Irwin Mitchell, said they were “pleased” to provide Emily’s family with “the answers they deserve,” but “nothing will make up for the anguish and pain they continue to face”.

She added: “Some of the evidence heard during the inquest is extremely worrying. It’s now vital that lessons are learned to improve patient safety for others and stop young and vulnerable teenagers falling through the cracks between child and adolescent and adult mental health services.

Emily’s parents Quinton and Renata issued a joint statement after the inquest concluded, paying tribute to their “beautiful” and “talented” daughter.

They said: “Emily was a very talented person. She was passionate about music, she played cello and electric guitar. She would spend hours creating her art at home. Emily loved nature, long walks in the forest and was also passionate about horse-riding.

They continued: “Emily was beautiful inside and out but sadly really struggled with her mental health. We tried everything we could to get her the care she deserved but she tragically took her own life leaving us behind in agony, pain and despair.

“Our family and our lives have been broken into pieces and we now feel an emptiness which cannot be rebuilt.”

They added: “We’ll always be upset and angry at how when Emily needed the help the most, we feel she was let down.”

They said the process had been “traumatic” but was “something they needed to do” to honour her memory.

The spokesperson for NELFT said in full: “We would like to offer our heartfelt condolences to Emily’s family and loved ones.

“We will continue to work to improve our services, including through the implementation of a new, more patient-centred, individualised, and thorough way of assessing risk, as well as co-designing personalised safety management plans with our patients and their families.

“We have also been working hard to make improvements in working between teams and to medical reviews for patients.”

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