Coroner blames gross NHS failures for death of bullied schoolgirl, 15, who hanged herself at home after repeated self-harm and suicide attempts

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A 15-year-old girl found hanged at home died a as a result of 'neglect' by the NHS, an inquest heard.

Becky Romero was discharged from a psychiatric unit despite carving 'my fault' into her forearm on the morning of her release. 

Her family pleaded with doctors not to discharge Becky from mental health care - and days later she was found dead by her father.

The tragic teenager was let down by a 'gross failure to provide basic medical attention', a coroner found. 

Becky's mother, Nicky Romero, 46, said that the conclusion of the inquest was 'a little bit of justice'.  

Becky Romero, 15, was let down by 'gross NHS failures' an inquest heard after she was found hanged at her home in Bristol 

The troubled school girl was victim to more than a decade of bullying before her death earlier this year.   

She struggled with mental illness and was picked on at school since the age of four, the hearing heard.

In the months leading to her death she tried to commit suicide three times and regularly self-harmed.

Becky, from Bristol, was then admitted to Pebble Lodge psychiatric unit in Bournemouth 80 miles away from her home.

She told psychologists she had no friends in Bristol and became 'heavily invested' in relationships with people on the internet.

On the morning of her discharge meeting on July 13 Becky had cut herself repeatedly. 

Parents Tony and Nicky Romero had questioned why Becky was being released in a conference call with a doctor at the unit, the inquest heard. 

Despite this she was released from care the following day.  

Her body was found by father Tony, 47, on Wednesday, July 19 - just five days after she was released from Pebble Lodge. 

Coroner Maria Voisin found the NHS as a corporate organisation contributed to Becky's death.

She found the service that was supposed to be looking after her was so under-funded and under-resourced its failure 'contributed to her death by neglect'.

Tony, 47, told the inquest: 'I thought it was ludicrous.

'I spent the whole hour saying it wasn't right, that surely, given she had cut herself worse than ever before the night before, and was still having suicidal thoughts... this would mean she would have to go back.'  

Almost all of the failings could be put down to a lack of resources, staff, beds and facilities, mainly in the Bristol area, Ms Voisin heard.  

Becky's mother, Nicky Romero, 46, said: 'I can't say I'm happy - that is the wrong word because my daughter is dead, but I do feel like this is the start of getting justice for Becky.' (pictured: Darren North, Nicky Romero, Tony Romero and Ana Romero)

Becky's care was not as good as it could have been because there were no beds or places available at the city's only adolescent mental health unit, Riverside, around six weeks before her death. 

Ms Voisin said Becky's death was accidental - in that it could not be certain she intended to take her own life - but that it was the result of neglect.

She is now writing reports to Avon and Wiltshire Mental Health Partnership (AWP), Dorset Healthcare and NHS England over a catalogue of failings.

AWP said it took the coroner's lengthy criticisms 'extremely seriously'.

Dorset HealthCare NHS said it had 'conducted our own investigation and are implementing a number of changes as a result of that'.

A spokesperson for AWP said: 'We offer our sincere condolences to the family and friends of Rebecca Romero at this difficult time for them.

'We note the criticisms highlighted by the coroner and take them extremely seriously. The Trust will work closely with partner organisations to ensure greater communication and coordination going forwards, in part to respond to the coroner.

Dorset Healthcare, whose psychiatrists discharged Becky on July 14, said: 'We wish to express our sincere condolences to Rebecca Romero's family and friends at this time.

'As well as contributing to the inquest, we have conducted our own investigation into Rebecca's death and are implementing a number of changes as a result of that.

'We are committed to learning from serious incidents and will consider the coroner's findings carefully in order to determine whether additional changes to practices are required.'

Becky's mum Nicky, father Tony, aunt Ana and Nicky's partner Darren North were in the hearing throughout the two and a half days.

Afterwards, Nicky Romero, 46, said she was relieved at the verdict.

'I can't say I'm happy - that is the wrong word because my daughter is dead, but I do feel like this is the start of getting justice for Becky.

'She was failed.

'I was hoping someone would say 'we've done things wrong' because obviously we know that so many things were done wrong, so this verdict goes way above and beyond what I expected, and Becky's got a bit of justice today.'