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17:24, 22 MAR 2017, Updated19:34, 22 MAR 2017
NOTE: A post-mortem determined that Courtney had been taking the medications prescribed to her, including: the sedative Zopiclone, the opioid Tramadol, and two SSRI antidepressants – Citalopram and Sertraline.
A teenager being treated for depression hanged herself in her bedroom after writing the words ‘To die would be an awfully big adventure’ on the wall, an inquest has heard.
Courtney Davis, 18, was discovered hanged by a family member who found the door of her room locked and had to force their way in, a coroner was told. On the wall she had drawn pictures of a person hanging.
The court heard Courtney’s body was formally identified by her mum Violent Johns, who was found ‘completely distressed’ lying on the bed holding her daughter’s body by Detective Constable Katie McKirk.
The teenager, of Moreton in Marsh, Gloucestershire, was being treated for depression at the time of her death but had been assessed as being only a medium risk of suicide, the Gloucester inquest was told.
Various medical and care agencies had been working with Courtney, but because of her outbursts of anger and aggression they were more concerned at the risk she posed to others than to herself, assistant Gloucestershire coroner Caroline Saunders was told.
A doctor who assessed her in October 2015 felt she was severely depressed but said: “But the last time I saw her I did not consider she was actively suicidal.
“Her suicide risk was medium. Her risk to others was assessed as high.”
The coroner recorded a conclusion of suicide on Courtney, who died on April 22 last year.
Speaking of her history, the assistant coroner Ms Saunders said: “Courtney had a history of autism, post traumatic stress disorder and mild learning difficulties. These exhibited themselves in a disturbed behaviour pattern.
“She had a history of self harming and had taken an overdose in the past. She posed a risk to herself and others.
“She had support from a number of agencies. In August 2015 she was referred by her GP to the mental health services, mainly due to eating problems.
“No thoughts of suicide were noted at that time.”
The coroner said that on October 14, 2015 Courtney was seen by psychologist Dr Chloe Constable and although the teenager was having suicidal ideas she expressed no plans to act on them.
An assessment by Dr Constable on November 2 found she was suffering from severe depression but a psychiatrist who saw her two days later did not consider her suicidal, the court was told.
Neither did her GP Dr Christopher Morton when he saw her on April 6 last year, just two weeks before she took her life.
Dr Morton told the inquest that when he saw her on April 6 he asked her about suicide and she said she would not do it because she would not want to hurt her family.
“I think she said she had thought about it but would never do anything about it,” he stated.
The inquest heard that in April 2015, while staying at the Tumblewood care centre for troubled girls in Wiltshire, Courtney was admitted to hospital in Bath after overdosing and self harming.
That followed the death of a friend at Tumblewood.
The coroner said one of the problems faced by the agencies was that Courtney failed to attend a number of appointments, even though a taxi was provided by the 2Gether Mental Health Trust to get her to them.
“But there is no evidence that any system designed to encourage her to attend consultations would have prevented her death,” said Ms Saunders.
“On 22nd April she was found deceased in her bedroom at home. She had hanged herself. I am satisfied neither medication nor alcohol contributed to her death.”
Coroner’s officer Terry Onions told the inquest that Courtney had gone to her room early in the afternoon of April 21 but that was quite normal and there were no concerns for her.
It was at midnight that a family member went to check on her and found her her hanged, along with the images and text on the wall, Mr Onions told.
Ann Gould of the council-run Families First Plus team in the Cotswolds said they helped Courtney between October 2013 and September 2014 at her mum’s request and then again in January last year when Ruskin College referred her.
There was concern at that time that she posed a risk of harm to her sister.
Dr Constable told the inquest that Courtney had a history of ‘anger and challenging behaviour’ and suffered ‘extreme aggression.’
Gordon Benson of the 2Gether NHS mental health trust told the inquest he chaired an internal review into the events leading to Courtney’s death.
The outcome had been to try to ensure that when multiple services and agencies were involved with someone like her, who failed to attend appointments or engage, there would be a ‘more unified’ approach.
He said new software is also being developed so that key information about a patient like Courtney would be available to all agencies from one portal.