A coroner has said there were “considerable and troubling delays” in the mental health care of a 14-year-old girl who died by suicide.

It comes after an inquest into the death of Erin Tillsley, from Great Cornard, near Sudbury, who was found by her father in her room on July 14 last year and was declared dead at the scene. 

Coroner Darren Stewart OBE said Norfolk and Suffolk NHS Foundation Trust (NSFT) had an “inadequate record keeping” system, however he added no failure in care or treatment made a material contribution to her death as an immediate risk could not have been foreseen.

Her family described Erin as a “bubbly, bright and loving young person who exuded warmth and charisma and a person whose company was uplifting”.

The inquest heard she was referred to NSFT on January 4 last year after an overdose on New Year’s Eve several days earlier.

It was not until May 5 that a member of the children and family and young person’s mental health team spoke to her and her father over the phone and made a plan for counselling support.

The court heard she did not receive any further contact from NSFT and died after a few months later.   

Mr Stewart said after the overdose Erin was at first only referred to a school nurse as the overdose was deemed accidental.

However, Mr Stewart said he was not convinced of this judgement because of other self-harming behaviour and asked the Trust to provide evidence to explain how guidelines around self-harm are being implemented.

The court heard there had been a decline in Erin’s mental health since 2022 and around the time of her death she had been staying at home instead of going to school despite efforts to get her in by both parents and teachers.

A police investigation ruled out bullying as having any influence and her father said there “was no particular reason” why she began avoiding school other than her self-diagnosed anxiety and depression.

Mr Stewart concluded Erin died by suicide.