Community mental health services "missed opportunities" before a "beautiful and amazingly clever" young woman took her own life, an inquest has found.
Flur McDonald, 24, died at a railway level crossing in Birkdale on January 29 2019.
Her devastated family previously described the pharmacology student, who was the first in her family to go to university, as "the most delicate, beautiful and amazingly clever young woman" and "the best baby sister."
READ MORE : Woman, 24, who took own life 'had the most beautiful soul'
An inquest held today (November 10) at Bootle Town Hall heard the she suffered from "serious, complex and longstanding mental health conditions including depression, anxiety and anorexia nervosa."
The death of both her parents in a short space of time was also said to have "deeply affected her."
Passing a verdict of suicide, Coroner Julie Goulding said based on witness testimony, her death "appeared to be a deliberate act."
At the time of her death, Flur was receiving support from multiple community teams under Mersey Care including North Sefton Community Mental Health Team and Liverpool and Sefton Eating Disorder Service.
The court heard that Flur had met with a community mental health worker on an 'ad hoc' basis on January 24 2019, five days before her death, due to her own concerns about depression.
Evidence read out in court stated that some staff "directly involved in [Flur's] care" did not have access to information help by other care staff and teams, including references to previous overdoses in 2010 and 2018.
It was also found that some information entered on risk assessments had been copied and pasted from previous assessments, instead of being updated.
The coroner said: "Maybe the pressure of working in a busy mental health team could increase the temptation to copy and paste [information on risk assessments]" but stated the act "could not be attributed to an act of omission."
Following Flur's death it was recommended that mental health risk assessments should updated after every meeting with service users, whether 'ad hoc' or planned and that the use of 'copy and paste' should be avoided.
However the care given by community mental health teams was described by the coroner as being of a "high standard."
In her summary, Coroner Goulding said: "Some opportunities to undertake an in-depth risk assessment and update care plans were missed."
She added however that it "is not possible to say if these missed opportunities contributed to the death."
Speaking in court, her brother Ryan McDonald said: "She was highly let down [by mental health services.]
He added: "We don't have a sister anymore."
The coroner decided a prevention of future death report into the case "was not necessary" adding since the time of Flur's death there had been "tremendous changes in how [mental health service] training takes place and how staff deliver services on the ground."
Following the verdict, Flur's brother Ryan told The ECHO : " Listening to the coroner reading through the failings in Flur's care over the years and more importantly in the last days of her life, opportunities were missed.
"But as a family we do believe that what the coroner said about being measures put in place straight after Flur died that will hopefully mean other young people don't slip through the net and end up taking their own lives.
"So prevention hopefully is key to what has come from my sister's passing."
Receive newsletters with the latest news, sport and what's on updates from the Liverpool ECHO by signing up here
