The body of 11-year-old Ursula Keogh was found in the Hebble Brook, Halifax, on January 22.
Coronor Martin Fleming recorded a verdict of suicide after an inquest into her death concluded today.
The youngster had died from a head injury sustained from a fall from height, Bradford Coronors Court was told.
The inquest heard that Ursula’s mother, author, lecturer and radio presenter Nicola Harlow, had completed two separate telephone appointments with doctors at her local GPs, who referred her to her school.
Mr Fleming said that in turn her school, Lightcliffe Academy, who were praised for their support of Ursula, kept referring the parent to the GP.
Telling the inquest that Mrs Harlow had felt ‘fobbed off’ by the practice, he said: “In that scenario people can fall through the net. We’ve got communication difficulties here that need to be ironed out. It needs to be addressed.”
Dr Steven Cleasby, of Spring Hall Medical Practice in Halifax, admitted there were flaws in the system and that GPs wouldn’t necessarily know what level of support was available at each school. He said in response to the case of Ursula, his practice now ignores NHS protocol instructing GPs to refer similar cases to school, instead dealing with individuals themselves.
Angela Jackson, Head of House at school “I had no idea why they were referring Ursula to us. We don’t have the facilities or the people.”
The Coroner suggested he would be writing to NHS chiefs in order to present a system which is clearer - and that schools and GPs should work closer together in such cases.
Ursula’s mother said: “If anything good can come of this, if we can do something national, that would be good.”
Ursula had been described as a bright and sensitive girl who had a passion for playing the violin.
But the court heard she had a history of self-harm and that alarms had been raised when her mother was told she was a visitor of ‘suicide websites’ on social media platform Instagram.
The inquest heard Ursula had handed a note to a friend on a school bus. It was addressed to the friend and instructed her not to open until after 6pm.
It said: “I’ve finally given up. I’ve stopped fighting.”
The court heard around the same time that she sent a text to her mum saying: “I’m so, so sorry. I love you.”
Coroner Martin Fleming recorded a verdict of suicide and ruled out any third party involvement or any other possibility, including that it may have been an accident.
He added: “It’s very difficult to reconcile in the case of such a young girl.
“She was an exceptionally intelligent girl, we’ve heard that she was a model pupil and it’s no wonder that this tragic and unexpected death devastated her family and all who loved her. And there were many that did.
“It’s clear Ursula was a troubled young girl. She was much loved and much supported and she didn’t give any cause for anybody think she was harbouring such dark thoughts.
“The communication between the GP and the school could have been better, this has been admitted here today.
“Goodness knows what the family is going through and what they continue to go through.”