A popular teenager killed himself after failing to make the grades for university and splitting from his girlfriend, an inquest heard.
Former Tiffin School student Charles Suen wanted to retake some of his A-levels after he struggled with school and missed out on his first choice of Edinburgh University the previous year.
The 18-year-old dyslexic was suffering from depression and suicidal thoughts after his best friend went on to study at the university and other friends moved elsewhere.
The day before he committed suicide, Charles – known as Charlie – had decided to withdraw his bid to reapply to other universities, which he said would be his salvation.
His father found him hanged from his bunk bed at his Kingston home on May 4, 2010, West London Coroner’s Court heard.
Speaking at the inquest on Tuesday, February 7, Charlie’s mother, Loretta, said: “He was talking about how going to university would be his salvage and I asked him what his plan B would be if he didn’t get in. He said his plan B was to take his life.”
During the inquest, concerns were raised about the delay in Charlie’s referral for psychological therapy and over the prescription of anti-depressant citalopram The teenager had visited his GP since October 2009 for his mental health problems.
He was referred to Kingston Rightsteps for psychological therapy but because of staff shortages he was not seen until February, three-and-a-half months later.
He killed himself in May 2010, five days before his 19th birthday.
After the inquest Mrs Suen said her son, who had learning difficulties and struggled when he attended school, was “badly let down”.
She said: "In our opinion, serious errors were also made in terms of the medical treatment he received.
"We cannot help but feel that had Charlie received the appropriate help he needed, when he first presented [himself] to the health service, he might still be with us today.
"Our only consolation at the time of his death, was that he was no longer in pain. Our expectations from this inquest process, was that the truth would finally be aired and possibly acknowledged. We owed this to Charlie."
Coroner Elizabeth Pygott said: “It is clear there had been a delay in Charlie being seen but I have to say it’s too remote to say that the delay was actually directly causative of his death.”
Speaking at the inquest, his GP Michael Desouza admitted he could have pressed for the teenager to have received quicker treatment.
He said: “We are to blame to some degree for Rightsteps not taking quicker action; we should have chased this more.
“There was not good enough communication between me to them or them to me; this was not adequate especially in the circumstances of what happened.”
The GP had also prescribed Charlie the anti-depressant citalopram, 11 days before his death.
The drug is blacklisted for under 18s and Dr Desouza said he felt it was appropriate for Charlie as he approached his 19th birthday.
Citalopram is used to treat a variety of mental health problems and can improve symptoms such as depression and anxiety.
In the early stages of treatment citalopram may intensify depression and suicidal feelings, increasing the risk of self-harm or suicide, but as the drug starts to work the risks decrease.
Mr and Mrs Suen raised concerns over its prescription to their son and the lack of communication and involvement they had in his treatment.
Mr Suen said: “Although he was 18, just 18, shouldn’t they be asking him ‘Do you want your parents to come?’. Shouldn’t they be co-ordinating, communicating between us?”
Kingston Rightsteps said steps had been taken to address the family’s concerns, which were complicated by patient confidentiality and the difference between being chronologically 18 and emotionally and socially much younger.
During the inquest Dr Desouza and psychologist Dr Mandy Oliver said they had also begun to think Charlie may have had Asperger syndrome and, despite his suicidal tendencies, were surprised to hear of his death.
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