Suzanna Strong of Deerfold, Astley Village, was found dead in woodland near to St Michael’s Academy, off Astley Road, on November 21, 2018.
A handbag found nearby contained a mobile phone with instructions of how to find several typed notes on her phone and laptop.
Preston Coroner’s Court heard that Suzanna, known as Suzie, had been admitted to Shawbrook House in Leyland in February 2018, a facility for adolescent mental health services. While there, consultant psychologist Dr Rajeer Biradar diagnosed recurrent depression.
He told the inquest: “Suzie had been expressing suicidal thoughts since the age of seven, which were constantly present.”
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He added: “She had given herself a one-year time frame in 2017 to see if things would improve for her.”
Suzie had broken up with her boyfriend and had been prescribed anti-depressants shortly before being admitted to Shawbrook House. But although deemed high-risk to herself, was not thought to be at immediate risk of suicide. She was later referred to a forensic child and adolescent mental health (CAMHS) team.
A more detailed assessment was carried out, the results of which were still outstanding when Suzie decided not to continue using services during a meeting on September 20, 2018.
Lynne Charnley carried out an investigation for Lancashire Care Foundation Trust, which ran the services supporting Suzie.
She raised concerns there was an absence of care planning, risk management plans hadn’t been updated, there were gaps in records and confusion over Suzie’s discharge from CAMHS.
She said: “It looked in every sense she had been discharged, but she hadn’t”, and acknowledged that Suzie had not had any support since the meeting on September 20.
Ms Charnley said that none of the problems highlighted were a route cause of Suzie’s death and that several new frameworks and policies had been brought in to resolve the issues, including auditing of case management, introducing standard operating procedures setting expected of care, and developing a care co-ordination model.
Coroner Richard Taylor said the medical cause of death was given as asphyxiation by hanging, adding that toxicology results showed some antidepressants and alcohol in her system, but “not a significant amount”.
Giving a conclusion of suicide, he said: “There doesn’t seem to have been any real direction or leadership in the help given.”
He said: “The very clear notes that were left showed the intention she had to end her life.
“On balance, suicide appears to be the conclusion that would be appropriate. There doesn’t seem to be any doubt in my mind this was a deliberate act.”