Melissa Martin-Hughes, who died in April 2010, started suffering "dark episodes" after developing severe acne at the age of 14.
Following a suicide attempt in August 2009 she was placed under the care of a mental health services "crisis team".
She was seen twice by a consultant psychiatrist after the incident, but he went on sick leave, and "shambolic" communications at the mental health trust meant that professionals failed to provide alternative support for the teenager, despite repeated requests for help from her parents.
Melissa had turned 18 and was being moved from child and adolescent mental health services (CAMHS) to adult provision.
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