An inquest into the death of a Workington teenager found that the events leading up to her death were a cry for help.

After hearing about Karen Jane Edgar's empathy and insight, a coroner yesterday ruled that the 16-year-old had not meant to kill herself.

Karen, of Sycamore Garth, Little Clifton, was found by her mother late on April 7 last year, and was taken to the West Cumberland Hospital in Whitehaven.

She was pronounced dead in the early hours of the following morning.

David Roberts, HM senior coroner for Cumbria, recorded a conclusion of misadventure.

He said: "I'm satisfied this was not a deliberate act to end her life. She hanged herself but had intended to be found by her mother."

Mr Roberts described the incident as an utter tragedy and said it was a cry for help.

Karen's mother, Julie Edgar, described her as a beautiful and intelligent girl.

She said: "She was thoughtful and she had a massive heart."

Karen had two older brothers, Ian and Christopher.

Mrs Edgar told the inquest how her daughter was looking forward to going to the school prom later that year and had already bought a special outfit. She was also excited about doing her national citizen service and had secured a place in sixth form at her school, Workington Academy.

Grandmother Mary Edgley added: "Karen had a degree of empathy that was outstanding. I've never met anyone like her, she had more insight than mature people.

"Once she wrote a letter to me and there was an expression she used that struck me. She said: 'You've loved me for 16 years, but I've loved you the whole of my life.'"

Mr Roberts will write to the NHS Cumbria Partnership Foundation Trust, which runs the county's mental health services, and the secretary of state Jeremy Hunt about failings in the care Karen was given prior to her death.

The inquest heard that the student had been referred to the NHS's Child and Adolescent Mental Health Services (CAMHS) in October 2015 and received care and treatment throughout the period leading to her death.

Elaine Graham, senior practitioner, said Karen had presented with issues including suicidal thoughts, low mood and lack of appetite and had been treated for depression. Her difficulties focused mainly on the relationship and communication with her family.

She was prescribed anti depressants after only two one-to-one sessions. Six months prior to her death, Karen had been admitted to hospital after overdosing on paracetamol.

The inquest heard guidance issued by The National Institute for Health and Care Excellence (NICE) states prescriptions should be made after four to six sessions.

Dr Barry Chipchase, clinical director for CAMHS, said: "The people that assessed Karen thought she wouldn't use psychological therapy in a way that would be effective."

However Dr Chipchase admitted failings within her care, including the lack of a clear care plan, the lack of availability of family therapy, a failure to monitor the teenager closely when medication was introduced or changed, and the absence of a multidisciplinary team meeting around Karen's case.

Speaking after the inquest, Karen's parents Derek and Julie Edgar said: "We are still devastated following the events of last year and the tragic loss of our beautiful daughter Karen.

"We would like to take this opportunity to thank the police, paramedics, and hospital staff for their hard work and support at that time of Karen’s death. Special thanks to the coroner, Mr Roberts, for his thoroughness and willingness to work with the family during the inquest process.

"We as a family asked for professional help from CAHMS and the services that were provided fell far short of what could and should have been expected.

"We have worked closely with the NHS over the last year to provide feedback to improve practice within the CAMHS service and we sincerely hope the findings and recommendations for improved child services are taken on board and implemented.

"We never believed Karen had meant to take her own life and this has now been validated by the coroners misadventure verdict.

"We also convey our thanks to our family and friends for their love, help and support over the last twelve months."

Following the inquest Clare Parker, director of quality and nursing at Cumbria Partnership NHS Foundation Trust said Miss Edgar and her family were not delivered the high standard of service the trust strives to achieve and an investigation had been carried out.

She added: "As a result of this investigation we have made a number of improvements, particularly to processes, within our Child and Adolescent Mental Health Service teams. Along with other improvements we are undertaking a unique piece of work to have risk assessments, care plans, mental health assessments and correspondence with GPs all in one place electronically. This will make the processes much more robust and enables services to flag issues earlier.

"We have listened to what the coroner has had to say and will be looking at this case again to ensure that all possible lessons are learned from this tragic event. We would like to reiterate our condolences and our commitment to providing high quality care."