A “SWEET and bubbly” schoolgirl, 14, tragically took her own life after being 'bullied' at school and 'let down by the NHS', an inquest heard.
Bella Greer, of Blackpool, Lancs, was found unresponsive by her grief-stricken mum on October 5 last year.
Sarah had been going upstairs to ask her daughter if she wanted some cake at around 6pm when she walked in on the heartbreaking scene.
She performed CPR but Bella was sadly pronounced dead.
The tragedy came a month after the teen was referred for an "urgent" mental health assessment.
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Blackpool Coroners Court heard how the youngster had previously taken a drug overdose on 11 September.
Bella had been admitted to hospital and her GP sent a referral to Lancashire and South Cumbria NHS Foundation Trust.
But, the email was sent to a decommissioned address.
While the inbox was still being monitored, staffing issues meant the referral was not picked up, the Coroners Court heard.
Catherine Watts, nurse manager told the court: "One person left and another was off sick. It was an oversight.
"It would have been ordinarily checked."
After Bella's death, an investigation found triage and communication problems between teams.
Lancashire and South Cumbria NHS Foundation Trust said the issues had since been fixed through training.
A member of the Adverse Childhood Experiences (ACE) team helped Bella's family make a self referral on September 14, which was marked as "urgent".
This meant a triage review should have been held within 48 hours and an assessment within two weeks
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But it was not registered until October 3 due to "staff deficits", the court heard.
'Bullying'
The court was told how the 14-year-old did not display signs of depression, but had been bullied.
Bella had changed schools as a result, however the inquest heard how "unpleasant" behaviour towards the teen continued.
The inquest also heard there was no evidence to suggest Bella had been systemically bullied.
'Let down'
Bella's heartbroken mum described her daughter's tragic actions as "a cry for help" and did not believe she had intended to kill herself.
The day before her child's death, Sarah described going out for food with Bella and enjoying the day together, with no signs the teen would take her own life.
The young girl's grandmother, Dianne Harrop, broke down in tears as she told the inquest: "Bella was a really sweet girl - kind and loving and so generous.
"The family were let down by some of the services.
"She had been moved from two schools because of bullying. It didn't help.
"It is a tragedy but I do feel they were let down."
Assistant Coroner Louise Rae ruled that Bella had intended suicide due to a heartbreaking note left behind.
She told the inquest: "There were no immediate mental health concerns, no indication her mental heath deteriorated during a delay in assessing her."
The Assistant Coroner could not say Bella's death would have been prevented should there not have been a delay.
"Bella expressed an intention and went on to do so. Suicide is the most appropriate conclusion in this case," she concluded.
The grief-stricken family were not satisfied with the inquest and continue to claim Bella would not have taken her life if she had been seen by a mental health team sooner.
Ursula Martin, Chief Strategy and Improvement Officer at Lancashire and South Cumbria NHS Foundation Trust (LSCft), called Bella's death "regrettable".
She said: "We fully acknowledge the conclusion reached by HM Coroner into the death of Isabella Greer and I would like to extend our condolences to her family.
"The safety of those in our care is our utmost priority and the death of any patient while under any of our services will always be regrettable.
"Following Isabella's death, we carried out a detailed investigation into care delivery concerns, which identified triage and communication issues between teams.
"We take the findings very seriously, they offer us an opportunity to learn lessons so we can endeavour to do everything to try to prevent similar issues occurring.
"We have addressed the issues highlighted through enhanced training and reviewed communication protocols.
"Once again, our heartfelt sympathies go to Isabella's loved ones during this incredibly difficult time."
