Health services in Norfolk have been criticised by a coroner after it was revealed that a meeting into how practices could be improved after a teenager's death is yet to take place - two years after he died.
Tyla Cook, 16, who struggled with gender identity and mental health, died at the Queen Elizabeth Hospital (QEH) in King's Lynn on November 15, 2017, six days after being admitted for a drug overdose.
Tyla, of Church Road, Wretton, was taken to hospital on November 9, 2017, after NSFT staff at Thurlow House, in King's Lynn, learned he had taken an overdose.
The inquest heard there were various delays in getting Tyla to hospital and sedating the teen so he could be taken into A&E.
At the end of a five-day inquest at Norfolk Coroner's Court, in Carrow House, Norwich, senior coroner Jacqueline Lake hit out at the QEH, Norfolk County Council and Norfolk and Suffolk Foundation Trust (NSFT) for not having held a multiple-disciplinary conduct event nearly two years since the teen died.
The meeting would see health and care professionals discuss how best to support people in situations similar to Tyla's.
Issues were raised over which organisation should arrange the meeting, with QEH initially thought to be organising it before the Clinical Care Group (CCG) took control.
The East of England Ambulance Service (EEAS) are also involved in the event but Ms Lake commended it for being the only organisation to enquire about the meeting.
Ms Lake feared the meeting would "fall by the wayside" unless action was taken.
Questions were raised as to why independent investigations by QEH and NSFT were not able to find issues which were discovered by the CCG's investigation.
Tyla was also involved in the Community Eating Disorders Service but it took 11 weeks for him to be seen.
The inquest was told this was down to practitioner Elliott Robinson's case load but Ms Lake told the court the delay was not acceptable.
The NSFT was also found to not have not kept Tyla's written care and crisis plans up-to-date. Ms Lake said these would have been able to offer additional support to Tyla and his parents rather than having the plans discussed orally.
Ms Lake said these could have been avoided but she approved of action taken by EAAS and QEH since his death to improve leadership in critical situations and a rapid sedation protocol.
Tyla's death was ruled as a natural cardiac arrest caused by a drug overdose.
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