'Beautiful' teenager hugged mum and made heartbreaking request on day she took own life

Emily Burns, 18, had been diagnosed with anxiety, depression, and anorexia when she took her own life and an inquest heard how her family felt she needed better mental health care

A teenager 'beautiful inside and out' took her own life after 'slipping through the net' while being cared for by mental health services., an inquest heard.

Emily Burns, of Waltham Forest, London, told her mum that she thought her medication needed to be increased on the day of her death in May 2023.

She had been diagnosed with anxiety, depression, and anorexia and was put under the care of child and adolescent mental health services (CAMHS) run by North East London NHS Foundation Trust.

But when she turned 18, the decision was made to transfer her to her GP, without a review by a senior doctor. She took an overdose and was admitted to hospital the same day. The sixth-form student and aspiring costume designer was then transferred to an adult home treatment team, where she repeatedly asked for a review of her medication and therapy.

She hugged her mum before school going to school on the day she died and said she believed her medication needed to be increased as it was not working. Emily’s parents, Renata and Quinton, have now spoken about the 'despair' they feel over their daughter’s death and are calling for improved mental health care for young people.

Coroner Nadia Persaud concluded '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 inadequate," she added, reported EssexLive.

Charlotte Stawiska, the specialist medical negligence lawyer at Irwin Mitchell representing Emily’s family, said: “This is an incredibly tragic case and sadly one of a number we’re seeing where vulnerable young people with mental health difficulties haven’t received the care they deserve.

“For many months Renata, Quinton and the rest of Emily’s family have held a number of concerns about the events that unfolded in the lead up to her death. They were left not only trying to grieve for Emily but also potentially facing a complex inquest system alone where the health providers involved in Emily’s care would have access to their own legal teams to represent them.

“While we’re pleased that we have been able to provide Emily’s family with the answers they deserve, nothing will make up for the anguish and pain they continue to face.

“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.”

After Emily was diagnosed with an underactive thyroid and told it could make her gain weight, she became distressed and was transferred to the eating disorder service in November 2021. Then after a panic attack, she was referred to CAMHS at the end of 2021. She started taking anti-depressants in February 2022 and was referred for psychotherapy that April.

But the coroner found she 'slipped through the net', only receiving a short courses of therapy after a lengthy delay which was 'inadequate' for her needs in January 2023. She was discharged from CAMHS in March 2023 after a review by a junior doctor and took an overdose the same day. She got one medical review at the end of the month by the home treatment team.

When she said her medications were not working, a plan was put in place to restart her anti-depressants and to be referred for more therapy. However, she only received an initial assessment from an unqualified therapist on May 5 2023. Four days later on May 9 she died by suicide.

Ms Persaud recorded a narrative conclusion that Emily took her life whilst suffering from a partially treated mental health disorder. The coroner said she heard evidence 'relating to failings in the care provided to Emily' but did not find on the balance of probabilities that any aspect of care directly contributed to the teenager’s death.

In a joint statement after the hearing Emily’s parents 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.

“Emily wanted to be a costume designer for the theatre and film industry. She was a very hard-working person always dedicated to her work and was about to start university.

“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.

“Emily had so much promise and all the hopes, plans and dreams she had will never get to be fulfilled. We’ve experienced the greatest loss that a mum and dad would ever have - the loss of a child. The circumstances around Emily’s death will affect us for the rest of our lives. We’ll always be upset and angry at how when Emily needed the help the most, we feel she was let down.

“The inquest and listening to the evidence as to why Emily died has been traumatic, but it was something we needed to do to at least honour her memory. We’re incredibly grateful to our legal team for their support. Legal Aid is limited for inquests and we did not qualify. Had they not agreed to represent us we’d have struggled with navigating the inquest process while still struggling to come to terms with our daughter’s death.

“All we can hope for now is that by sharing our story we can help improve care for others. It’s too late for our family but hopefully not for other families.”

A spokesperson for NELFT said: “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.”

For emotional support you can call the Samaritans 24-hour helpline on 116 123, email jo@samaritans.org, visit a Samaritans branch in person or go to the Samaritans website.