Ceara Thacker: Why didn't someone tell us our daughter was in trouble?
Ceara Thacker's parents believe she "fell through the cracks" between various mental health services while at university. Speaking after a coroner ruled their daughter killed herself, they say they hope lessons can be learned from her death.
The end of Ceara Thacker's first year at the University of Liverpool was just weeks away.
She seemed upbeat and happy when she returned home for the Easter break, her father Iain recalled.
The 19-year-old was excited about a big family party and to see her boyfriend Sam - and his dog - who still lived in Yorkshire.
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Things appeared to have been going well for Ceara. The philosophy student had always been a voracious reader and a deep thinker and the course seemed like a good fit for her.
She had loved the atmosphere of Liverpool when she visited on an open day, and had made good friends.
Yet just a few weeks after she returned to Liverpool after that Easter break at home, Ceara was found dead in her halls room. A coroner ruled she died by suicide.
It is the stunned silence Iain Thacker remembers most about the moment he and Ceara's mother Lorraine were told, just hours after their daughter had died, that she had previously attempted suicide.
"Straight away we looked aghast at each other and thought, 'How can we not know this?' 'How can we not be told this?'" he said.
Ceara had struggled with her mental health since she was 13 and first showed her mother a self-inflicted cut on her hand.
Throughout her early teenage years, Ceara was helped by Child and Adolescent Mental Health Services, commonly known as CAMHS, and had always been fairly open about her mental health with her parents.
She also seemed able to seek professional help when she felt she needed it, Iain said.
Ceara declared her mental health problems on both her university application, and it was followed up by the University of Liverpool.
"I remember she couldn't wait for us to leave," Iain said of the day he dropped her off at the halls of residence.
Yet over the next eight months, unknown to her parents, Ceara would seek help for mental health problems several times before she died, the inquest heard.
Just a few weeks after her arrival in Liverpool, Ceara attended A&E and told a mental health nurse she was struggling. She later attended a GP appointment and was prescribed anti-depressants.
Into the new year, Ceara continued to struggle. On 21 February 2018, the coroner heard she had texted a friend to say she had taken a number of tablets. The friend took Ceara to the reception in the halls of residence and told the staff member there.
They ordered her a taxi to get to A&E but nobody escalated the incident to other parts of the university, including its mental health team.
After being treated for the overdose at the Royal Liverpool Hospital, Ceara was assessed by two mental health nurses.
The inquest was told how records of that assessment were incomplete and not sent to Ceara's GP. One of the nurses, Lindsay Cleary, told the inquest she was sorry for the error, which came after a busy shift.
The day after, Ceara sent an email of her own accord to the university's mental health team requesting an appointment.
She did not receive a response for almost two months due to what the university said were "exceptional circumstances" - including a strike by staff at its mental health advice service.
Ceara was eventually offered an appointment, her first with the campus mental health team, but none of the plan put together to help her at the meeting was acted upon.
She died two weeks later on 11 May 2018.
The University of Liverpool said it had since "conducted a thorough review of the support Ceara was offered" and had also recruited more staff at its mental health advice service.
After her death, a letter from Ceara's GP practice was found in her room, asking her to get in touch. A handwritten note on the page urged "do it!!" underlined and in capital letters.
"We don't know why Ceara didn't feel able to tell us what was going on. However, we feel very strongly that someone in a position of responsibility needed to ask her if she wanted us to be told," Iain said.
"If we had been told what was happening with Ceara we would have made a difference."
'Progress being made'
Rosie Tressler, the chief executive of mental health charity Student Minds, told the BBC she was optimistic about the progress being made by the higher education sector with innovative schemes being tried and tested by institutions.
At Bristol University, where about a dozen students died through suspected suicide in a short period, all students are asked to "opt-in" to a policy which automatically informs a parent or guardian if there are concerns for their wellbeing in the future.
"We can't rest on our laurels. With so many challenges, we can't stop working on student mental health. It will require partnership between universities, NHS services and the student voice," Ms Tressler added.
What did the coroner say?
Liverpool area coroner Anita Bhardwaj concluded that Ceara died by suicide. She said Ceara experienced an "unacceptable delay" in accessing the university's mental health service and there were several missed opportunities to refer her for mental health support.
Mrs Bhardwaj said there was no record of discussions between medical professionals and Ceara about contacting her family.
She added: "It is difficult and unclear whether Ceara would have had a different outcome had she had additional mental health appointments, been given an urgent appointment, and had family involvement."
What did the University of Liverpool say?
Gavin Brown, of the University of Liverpool, said it had "instigated a number of improvements to mental health support services" with a £500,000 investment and new guidance on asking students about sharing information.
He said some students might not want to inform family and that in those cases staff would work with students to "identify alternative support networks".
The university has chosen not to adopt a campus-wide "opt-in" policy to automatically inform parents of concerns for a student's wellbeing.
Information and advice
If you or someone you know is struggling with issues raised by this story, find support through BBC Action Line.