''The love and support you gave was phenomenal. There was nothing you could have done' - coroners words to parents of student who took her own life
Hannah Bharaj fell from a balcony at a Cheadle department store in July 2018
Last updated 5th Jul 2019
The inquest into the death of a Bolton student, who fell from a balcony at a shop in Cheadle, was suicide.
Hannah Bharaj had been battling depression and anorexia for months and was a patient at The Priory hospital in Cheadle at the time of her death.
The coroner told the court that Hannah's mental health suffered after her A-Level results and the death of her grandfather.
She took a break part-way through her second year at Birmingham University, as her weight plummeted and the coroner described how she was 'deteriorating'.
She was admitted to Oak Trees Eating Disorder unit at Clatterbridge Hospital in the Wirral, where she remained for nearly six months.
The coroner said the team there did not make serious attempts to deal with the joint issues of her anorexia and depression, and that she was only assigned a psychologist three months into her stay, because the team could not find someone to fill the position.
During her stay, she self-harmed and her suicidal thoughts continued, but she was discharged in May 2018.
The coroner said her discharge from the facility was 'concerning' for a number of reasons.
There were no notes handed to her GP, so they were unaware that she was suicidal and prescribed her a month's worth of anti-depressants.
Two days after she was discharged, her uncle died and her mother - Sarah - worried about the impact it would have on her.
She had a counselling session a few days later, during which she admitted having suicidal thoughts but this was never disclosed to her family or her GP.
Within days, she had taken an overdose and was admitted to hospital.
The coroner said there needs to be a better consideration of the risk patients pose if they have suicidal thoughts, and that communication between Trusts and GPs needs to improve, as well as information being shared with family members.
When Hannah was admitted to The Priory, a month before she died, she was placed on an acute psychiatric ward where - the coroner said - the team were not specialists in eating disorders and did not know how to manage her condition.
The ward was described as 'scary' and 'frightening' for a young woman with complex mental health problems who was surrounded by older patients.
Her psychiatrist at The Priory told the inquest that he did not believe the facility was suitable for her needs, as her anorexia was the driving cause of her depression.
He had tried to arrange to move her back to the eating disorder facility but was unsuccessful.
Over the course of her stay, she made very little progress and the coroner described how her sense of 'hopelessness' had increased. While at the eating disorder facility, she had looked forward to the future but by the time she moved to Cheadle, that feeling had disappeared.
She was allowed to leave the facility once a day, to spend time with her parents. It was during one of these visits that she fell to her death, suffering catastrophic brain injuries that proved fatal.
The coroner told Hannah's parents that the support they gave her throughout her life was phenomenal, and that there was nothing they could have done differently.
But she said there were issues to do with her care and the treatment she received that needed to be addressed.
She criticised the communication between different hospital Trusts and GPs and called for better information sharing with parents and carers.
She also asked that universities address the way they structure therapy and welfare services, so that they improve the way they address early signs of depression and anxiety.
She said she would write to the relevant organisation to make her requests.