Noah Lomax, from Crookes, was found dead in Conisbrough, Doncaster, on August 2 last year, the day after being reported missing by his family.
An inquest, which concluded he had deliberately leapt to his death on August 1, heard how the teenager had a history of mental health problems, had attempted suicide in 2017, and his mother learned last summer that he had been planning to take his own life.
However, Sheffield Coroner’s Court was told there had been a delay in getting him the help he needed, due to poor communication between his doctor and mental health experts.
Had his case been given the priority it deserved, assistant coroner Angharad Davies found, he would have been seen days before he ended up taking his own life.
However, she stated that it was impossible to say whether or not this might have saved him.
Ms Davies noted that Sheffield Children’s NHS Foundation Trust, which is responsible for Sheffield Child & Adolescent Mental Health Service (CAMHS), had admitted ‘non-causative failings’.
The trust accepted that its protocol at the time was ‘not sufficiently robust’ and changes have since been made.
CAMHS now calls doctors to request extra details when needed, and contacts GPs and families when referrals are declined.
It has also updated the guidance to help GPs fill in referral forms, improved information sharing with GPs and has plans in place to accept self-referrals from young people and their carers by next year.
However, Ms Davies believes changing the referral form to help under-pressure GPs may reduce the risk of future deaths, and she plans to write to the trust to make this point.
The inquest heard how in July last year, Noah’s mother Claire McGettigan was alerted by a friend of her son’s that he had confided plans to take his own life.
She took Noah to see his GP, Dr Heather Peat, at The Crookes Practice on July 9, and Dr Peat referred him to CAMHS for treatment.
However, the inquest heard how the referral was rejected as the form contained insufficient detail.
The mental health service wrote back to Dr Peat requesting more information, and she told how she had planned to ask for those details at a follow-up appointment with Noah and his mother scheduled for August 6.
Had CAMHS chased up the case and learned Noah had a plan in place to take his own life, the inquest heard, an urgent appointment would have been organised for July 30 or 31.
In her written conclusion published last Friday, Ms Davies wrote that CAMHS should have taken ‘proactive steps’ to obtain the missing information and had it done so it would have concluded Noah was at ‘high risk’ and required an urgent appointment within two weeks.
“Had the urgent referral been made Noah would have received an appointment with CAMHS on either July 30 or 31 when he returned from holiday,” she wrote.
”It is not possible to say on the evidence what effect a CAMHS appointment would have had on Noah’s state of mind and planning.
“Specifically, it is not possible to say that the lack of appointment contributed more than minimally, negligibly or trivially to Noah’s death.”
Sadie Simpson, of Switalskis Solicitors, who represented Noah’s family, said: “Noah’s family are really pleased that the coroner recognised there were failings on behalf of both Noah’s GP and the trust, and that she made a recommendation to prevent future deaths.
“They can only hope that from these obviously really unfortunate circumstances changes are made which could prevent more families going through what they are.”
Dr Jeff Perring, medical director at Sheffield Children's NHS Foundation Trust, said: “Our thoughts are with the family for the terrible loss of their son Noah.
“While it may not have made any difference for Noah, we have reviewed our processes and have made a number of changes to safeguard children being referred to CAMHS.”
He added that the trust had taken on board the coroner’s recommendation to review the referral form again, saying ‘this work is already underway’.
They told how a fundraising appeal launched in his memory has raised nearly £10,000, which is already helping young people like him from the LGBT+ community.
You can still donate to the Noah Lomax fund for LGBT teen mental health, at: https://localgiving.org/fundraising/noahlomaxfundsayit.
If you need to talk, you can call Samaritans on 116 123.