Gaia Pope died from hypothermia during a mental health crisis
An inquest into the missing teenager's death has concluded
Missing teenager Gaia Pope-Sutherland died from hypothermia after running away from her home while suffering from a mental health crisis, an inquest jury has concluded.
The teenager, who suffered from severe epilepsy, was reported missing from her home in Swanage, Dorset, on November 7 2017.
A search operation was launched in the Swanage area for the 19-year-old, including police, HM Coastguard, National Police Air Service, Dorset Search and Rescue and members of the public.
Her body was found by police search teams on November 18 in undergrowth between Dancing Ledge and Anvil Point, close to the Swanage coastal path.
A post-mortem examination found Miss Pope-Sutherland, who had been discovered in deep undergrowth, had died from hypothermia. An entomologist said he believed the latest she had been alive was November 9.
Her clothing was found scattered across a field as if she had been removing it while she walked and she could have been suffering from "paradoxical undressing" as she succumbed to hypothermia.
After deliberating for a day and a half, the jury returned a unanimous narrative conclusion that Miss Pope-Sutherland had died from hypothermia at some point between 3.59pm on November 7 2017 and 10am on November 8, which was "probably caused by her mental health and mental state on November 7 2017".
During the 11-week inquest, jurors at Dorset Coroner's Court in Bournemouth heard evidence from 78 witnesses.
The teenager had been diagnosed with post-traumatic stress disorder after revealing she had been drugged and raped by a man when she was 16.
At the time of her disappearance she was anxious about his imminent release from prison for unconnected sexual offences and had been experiencing "ongoing manic episodes" - fearing he was "after her".
The college student had also reported to police receiving indecent images via Facebook from a different man and was due to make a formal statement on the day she disappeared.
Miss Pope-Sutherland, who was a regular cannabis user, appeared "unsettled" on November 7 and left her aunt Talia Pope's home in Swanage at 3.40pm. The last known sighting was a short time later on Priest's Road.
The inquest heard the chief constable of Dorset Police had accepted there were several failings in the hunt for Miss Pope-Sutherland.
Many members of the teenager's family told police to search the area where her body was later found, as it was a favourite spot of her late grandfather.
Her mother, Kim Pope, tried reporting her missing and her aunt made five calls to Dorset Police in the hours after she ran off, but a formal missing person report was not logged by the force until 6.15pm.
She was then graded as at "medium risk of harm" and only upgraded to "high risk" nine hours after she vanished.
It meant the search for Miss Pope-Sutherland was slow to get off the ground, with one officer searching Swanage town centre that evening and a police helicopter combing the Dorset coast.
Extra officers were not drafted in, and a specialist police search adviser and senior officers were not informed.
A 300-metre search of where she was last seen did not start until the following day and from the wrong location, with officers "crying out for help", the inquest heard.
The teenager's father, Richard Sutherland, questioned whether police had directed enough resources to finding his daughter in the first 48 hours and should have searched the Dancing Ledge area earlier.
The inquest also heard that a police search co-ordinator retrospectively altered search records relating to the teenager.
There were several missed opportunities around Miss Pope-Sutherland's medical care in which she was seen four times in two years by psychiatric services.
The inquest heard the teenager had spent several weeks in hospital in February and March 2017 - where she was sexually harassed by a patient - having been sectioned under the Mental Health Act following a tonic-clonic seizure and developing postictal psychosis.
Miss Pope-Sutherland's sister Clara told the inquest her mental health had been a "ticking timebomb" since she learned the man she accused of raping her was to be freed.
She was further assessed in Poole Hospital in the October after her mental health worsened but later discharged and sent home without any community support.
Professor Matthew Walker, a neurologist who treated the teenager's epilepsy, said there needed to be better communication between professionals as he was never told about the October assessment, which he described as a "missed opportunity".
Epilepsy expert Professor David Chadwick said there were also "missed opportunities" to review her epilepsy drug treatment because of communication failures between doctors.
Furthermore, her social worker was never told of the assessment.