16-year-old Daisy French passed away at around 8pm on April 19 this year, after being struck by a train at Meadowhall train station.
Giving evidence at her inquest at Sheffield Coroners' Court today, Detective Constable Philip Hare, said that following a British Transport Police investigation into Daisy's death, he concluded she had 'deliberately' fallen into the path of the train.
DC Hare told the court how a notebook found among Daisy's belongings at Meadowhall train station detailed 'dark' thoughts she had been having about wanting to end her life.
Coroner Louise Slater revealed how Daisy had also written about feeling 'frustrated' that she was not receiving the help she needed, and that she was 'worried about what would happen' if she did not receive help.
In a statement read out in court Daisy's mother Samantha Kidd said that while her daughter, who she described as a 'bright girl,' had often told her that she wanted to end her life, she said she had not noticed anything unusual about Daisy's behaviour in the hours leading up to her death - other than the fact she had not put on make-up before leaving the house.
Ms Kidd said: "She seemed happy. She was walking around the house singing," adding: "Though Daisy had talked of her ending her life, almost weekly, I was shocked."
"I did everything I could to help Daisy, and I miss her terribly."
The court was told that Daisy's mental health problems first came to light in January 2013 when she attempted to take an overdose, aged just 13-years-old. Later that year, she was diagnosed with Asperger Syndrome, depression and non-organic psychosis - the latter of which was diagnosed after she told medics she had been 'hearing voices' and seeing things. She was also prone to self-harm, the court was told.
A witness statement from British Transport Police officer, Fiona Coyner, revealed how she came to Daisy's aid on two occasions on November 29, 2016 and March 15, 2017 when the teenager was found at Meadowhall and Sheffield train stations, respectively, in 'distress' and talking about wanting to end her life.
The court was told how Daisy had to be physically restrained to prevent her from committing suicide.
Ms Coyner described how she spoke to Daisy at length following both incidents. Following the incident in November 2016, Daisy told Ms Coyner that 'no-one could help' and described how she had tried to take her own life on 10 occasions in that year alone. Then in March, Daisy told Ms Coyner that she had tried to kill herself on 20 separate occasions.
After both incidents Daisy was detained under Section 156 of the Mental Health Act, and was then taken for treatment at a dedicated mental health suite at Northern General hospital. Sheffield Health and Social Care NHS Foundation Trust (SHSC) took the decision not to admit her as an in-patient after either incident, the court was told.
Daisy had been an in-patient at mental health facilities in Sheffield on a number of occasions between 2013 and 2017.
Responsibility for Daisy's mental health care was initially under the remit of Sheffield Children's NHS Foundation Trust (SC), and was officially transferred to the early intervention team at SHSC, which deals with mental health services for adults in the city, in December 2016, Sheffield Coroners' Court heard.
A patient would normally be transferred to the SHSC when they were aged 18, but Mr Davies confirmed that due to Daisy being diagnosed with a form of psychosis, this step was taken when she was 16-years-old instead.
Consultant Child and Adolescent Psychiatrist, Dr Steven Richard Hughes, who treated Daisy on behalf of SC, told the court that the transfer of Daisy's care to the SHSC began in summer 2016. He said he felt responsible for Daisy until December 2016 when he wrote to Daisy and the relevant agencies to confirm the transfer of her care.
Dr Hughes revealed that he was not informed of Daisy's attempt to commit suicide at Meadowhall train station in November 2016, and that the protocol in place meant SHSC would only have had to inform him of the incident had they taken the decision to admit her as an in-patient, as a result.
When asked by Ms Slater if SHSC's failure to disclose Daisy's in November 2016 suicide attempt to him and SC had resulted in a 'missed opportunity', Dr Hughes replied: "I would have preferred to have been told."
He added that he did not think it would have necessarily resulted in a different treatment outcome, had SHSC informed him of Daisy's suicide attempt, but refused to comment on whether the clinical decision made by SHSC not to admit Daisy as an in-patient was the correct one.
Ms Slater also questioned whether child psychiatrists from SC and adult psychiatrists from SHSC would have come to the same conclusions about the best way of treating Daisy.
Dr Hughes replied: "In some situations, a child psychiatrist would feel more confident, but in a situation like this I doubt whether an adult psychiatrist would differ from a child psychiatrist's prognosis on how to treat someone who has self-harmed as it's a fairly common issue for both types of psychiatry."
Daisy's inquest is due to conclude at Sheffield Coroners' Court tomorrow.
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