Eve Cockburn was 16-years-old when she deliberately stepped in front of a train near Greenfield Station in Oldham in September 2018.
The school pupil had been diagnosed with anxiety and depression at the age of 14, an inquest into her death previously heard.
Miss Cockburn had also been told that she had Autistic Spectrum Disorder (ASD).
The teenager, who had dreams of studying at Oxford University, had been admitted to a psychiatric ward at Fairfield Hospital on two occasions, and sectioned under the mental health act.
Her parents believe their daughter was not provided with suitable treatment for a child suffering with autism and anxiety.
Rachel and David Cockburn told the Heywood inquest they felt this contributed to the deterioration of their daughter’s mental health.
After hearing five days of evidence, Area Coroner for north Manchester Catherine McKenna concluded Miss Cockburn died as a result of suicide.
She identified key failings in the care of Miss Cockburn.
Ms Mckenna said there was a failure by the local Oldham social care team to undertake a ‘meaningful’ assessment in Eve’s case.
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The court heard that Miss Cockburn was at a risk of social isolation, and the social care team could have provided vital assistance to Eve.
Ms McKenna also highlighted an “inexcusable” failing by Saddleworth High School, to put a suitable plan in place for when the autistic teenager left school.
The inquest previously heard that school had been of great importance to the teenager, and the thought of leaving school ‘terrified her.’
In the days leading up to her death, Eve had been living at her home in Saddleworth with her parents and twin sister.
On the afternoon of September 4, 2018, she left her home and made her way to a section of train track near Greenfield Station.
Shortly afterwards, she was hit by a train.
A note of intent addressed to her family was found by police at the scene and at Miss Cockburn’s home address.
Mrs Cockburn described her daughter as a ‘lovely’ child who had a happy and healthy chilhood.
Eve excelled at school and was said to enjoy creative writing, with the hope to become an author.
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Mrs Cockburn said she noticed a change in her daughter’s behaviour on a family holiday when Eve was 14.
Her parents took her to see a GP and Eve was diagnosed with anxiety and depression.
By December 2017, Ms Cockburn said her daughter’s mental health began to deterioriate.
The court heard the student was ‘terrified’ about leaving school, and had recently been diagnosed with Autistic Spectrum Disorder.
In February 2018, Eve was admitted to the Hope Unit at Fairfield Hospital, after she disclosed to a therapist plans to kill herself.
The unit is an acute psychiatric ward for patients between the ages of 13 and 18.
Her father, David Cockburn said he did not believe this unit was appropriate for someone with anxiety and ASD.
The inquest heard the unit could sometimes be busy, noisy and had a quick turnover of patients.
Miss Cockburn was re-admitted to the Hope Unit in April 2018, after telling a friend she had made plans to end her life.
This time, she was detained under section two of the mental health act.
Due to a lack of beds, she was transferred to a unit in Warrington, before being transferred back to the Hope Unit.
The court heard that many of the patients on the ward were suffering with psychosis, and this upset Eve.
She was subject to 15 minute observations, meaning interaction with her family was regularly interrupted.
Eve was discharged in May, but during a holiday to Scarborough in July, Eve was reported missing after failing to return from a trip to the beach.
She was found by police around 12 hours later suffering from hypothermia, and was admitted to hospital in Scarborough.
Miss Cockburn remained there for a week before being discharged home.
By this time, her Mrs Cockburn had become extremely concerned about her lack of ability to support Eve.
Mrs Cockburn told the court that missing lessons and the uncertainty of plans after secondary school were causing Eve distress.
The inquest heard that an Educational Health Care Plan was not submitted by Saddleworth High School until the last day of term.
This meant that no plan was put in place for Eve’s future education upon leaving school in Summer 2018.
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Miss Cockburn’s case was also referred to the local authority’s social care team, who could have put extra measures in place such as respite for the family, or a personal assistant for Eve.
The court heard there was a failure by the local authority to make a ‘meaningful single assessment’ of Eve.
This meant Miss Cockburn and her family missed out from any additional help from the local authority
In the few days leading up to her death, her family told the inquest that Eve’s condition had begun to improve.
Mrs Cockburn described her as the “perfect daughter,” and said she had begun showing signs of affection for her family.
Yet on September 4, Eve made her way to the tracks near Greenfield Train Station and deliberately stepped in front of a train.
She was pronounced dead by paramedics at the scene.
Recording her conclusion, Ms Mckenna said while the failings outlined caused her ‘great concern,’ they did not lead or contribute to Miss Cockburn’s death.
Since Eve’s death, her family has raised over £4,500 for Young Minds, a mental health charity for young people.
More recently, they have set up a fundraising page for charities Childline and Papyrus (Prevention of Young Suicide).
Miss Cockburn’s family said in a statement: “The inquest has been quite a traumatic experience to go through, but it has highlighted failings in services that could have offered support to Eve and our family.
“Eve knew there was no support for her on leaving Saddleworth School, and she was terrified of moving on to 6th form.
“There was a huge strain on Healthy Young Minds who went above and beyond their call of duty. They tried desperately hard to support our family.
“I would also like to praise the pastoral support at Saddleworth who were in close contact with us and helped and adapted well to Eves needs, especially during her GCSE exams.
“The family will be working with numerous NHS bodies and Social Services to suggest improvements in their services for young people with mental health issues and ASD.
“These include trying to put adequate educational plans in place for pupils who have coped with mainstream education in their early life and then came to find it increasingly difficult as they got older.
“Additionally there are services in the NHS which are age related when the NHS has already recognised that they should be treating the patient and not the age, this is especially problematic with young people accessing mental health services at a time when schooling and so many other things are changing.
“We want to help with suggestions for improvements to the NHS, Social Services and Education so that there is more support in place for others who might find themselves in a similar situation in the future.”