Death of student, 19, ruled a misadventure by coroner

A 19-year-old student died at the Norfolk and Norwich Hospital, an inquest heard. 

The death of a 19-year-old student a result of misadventure, an inquest concludes. - Credit: Archant

A grieving mother has questioned why her 19-year-old daughter's psychological assessment was not escalated after a referral to mental health services.

Mary Robinson, who was studying travel and tourism at City College Norwich, died on January 31, 2021 at the Norfolk and Norwich University Hospital.

An inquest into her death was held on Friday, February 18 at County Hall, which heard how her mother, Claire Robinson, found her daughter unresponsive in her room two days before.

The inquest heard how the third-year student was living with her family in south Norfolk and had plans to continue her studies at university and to travel.

She had reported low mood and suicidal thoughts to her GP on September 23, 2020, and was referred to youth team mental health services.

It was classed as routine and she was placed on a waiting list for psychological assessment.

Following further contact, her GP made an urgent referral in November and again in December.

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From December 16, Miss Robinson received weekly telephone calls with youth mental health services while she remained on the waiting list.

On January 29, Miss Robinson contacted First Response, a mental health crisis line, for support after feeling anxious. Her family were out at the time.

She spoke with Belinda Paton, assistant crisis care practitioner NSFT, for around half an hour before the call ended at 20.44pm.

Mrs Robinson questioned why the case had not been escalated to a clinician or emergency services.

The practitioner said it was because Miss Robinson discussed "forward planning" such as going to work the next day and an appointment in a week's time.

The 19-year-old was later found at 9.30pm.

Mrs Robinson said her daughter wanted a psychological assessment, which she believed could have helped.

She said: "She wanted to go to Australia, to go to university. She had plans for the future."

Dr Lynda Meina, clinical psychology director of Youth Services, said a "disproportionate" number of referrals come in as urgent and that they are reviewed and triaged by the team.

She added: "We now have a much better communication system between acute colleagues and the First Response team, and all of the places where young people in crisis are likely to report."

Simon Milburn, assistant coroner for Norfolk, concluded Miss Robinson died as a result of misadventure.