A TEENAGER died suddenly on Boxing Day after overdosing on beta-blockers, an inquest has heard.
John Gittins, coroner for North East Wales and Central, recorded a conclusion of death by misadventure in the case of Gemma Louise Griffiths, 19, of Parc Hendy, Mold.
Evidence submitted to the Ruthin inquest by her mother Julia raised concerns about how her daughter's transition from youth to adult mental health services was handled.
She described how Miss Griffiths went to Westwood Primary and then Elfed High schools in Buckley, and then Argoed High School at Bryn-y-Baal, but experienced bullying.
She had been a travel and tourism student at Coleg Cambria, liked going out with friends but had struggled with a recent break-up.
Ms Griffiths had previously been diagnosed with emotionally unstable personality disorder.
Last November she had overdosed twice on paracetamol and the family were concerned that having been assessed in September, there was a lack of contact from the mental health team, that she was high risk and there was no care plan in place.
Her next assessment was on November 15 at Wrexham Maelor Hospital after a paracetamol overdose two days earlier.
Mrs Griffiths described how the family had enjoyed a good Christmas Day together but she was woken up at 2am on Boxing Day with her daughter shouting for her.
Miss Griffiths admitted she had taken beta-blocker tablets bought from America over the internet, passed out and was taken to Wrexham Maelor Hospital where she died.
A toxicology report confirmed Miss Griffiths had three times more than the fatal level of propranolol in her system and went into cardiac arrest.
Dr Masood Malik, a consultant psychiatrist/clinical director at Betsi Cadwaladr University Health Board who assessed Miss Griffiths in September, admitted the situation could have been handled better and said he would have expected a more up-to-date assessment to be carried out after she was referred to the community mental health team.
He added that when he assessed her, she was looking forward and making plans for the future.
Dr Malik said: "You cannot rely on an assessment carried out in September at a time when someone is in a good state of life."
Miss Griffiths' family are set to meet with Betsi Cadwaladr University Health Board in August to discuss their concerns.
Mr Gittins said he could not be certain that Miss Griffiths intended to bring her own life to an end when she took the tablets.
He said: "It is not clear to me that this is what she was intending to do."
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