A 14-year-old girl who told staff she wished to end her life on the day she died suffered an accidental death contributed to by neglect while under the care of the Priory, an inquest jury has ruled.
Amy El-Keria died after tying a scarf around her neck while receiving treatment at the Priory, which runs mental health services as part of a contract with the NHS.
The teenager was found in her room at Ticehurst House in East Sussex in November 2012.
A jury in Horsham ruled:
She died of unintended consequences of a deliberate act, contributed to by neglect
There was a failure to dial 999 quickly enough
A doctor was not called promptly
Staff were not trained in cardiopulmonary resuscitation (CPR)
Levels of staffing were not adequate
A lack of one-to-one time caused or contributed to Amy's death in a "significant" way
The jury agreed the response of staff was so inadequate there was a possibility that Amy may have lived if she had received proper care.
Staff did not assess the risk of her being able to take her own life in her room, and opportunities were missed to remove the scarf.
The jury also said the Priory failed to properly deal with the fact that Amy was being bullied, and staff failed to share details of the times the teenager had said she wanted to kill herself.
A delay in checking on her on the evening she died also contributed significantly to her death, while she should have been under even closer scrutiny, it said.
'Complex mental health problems'
Amy, who had a complex range of problems and mental health diagnoses, including attention deficit hyperactivity disorder (ADHD), Tourette's, oppositional defiant disorder (ODD), gender identity dysphoria and conduct disorder, was moved to the Priory in August 2012 after being asked to leave her specialist boarding school, High Close in Berkshire.
The inquest heard that, while at school, she had drawn a picture of herself hanging and had written underneath: "If only this could happen, but I haven't got the guts."
Amy was admitted as a "nervous" inpatient to Ticehurst House, following a referral by West London Mental Health NHS Trust. The referral came after she made several attempts to end her life throughout early 2012.
On the day she died, a member of staff found her door locked and realised Amy had decided to try to end her life, having informed a member of staff of her intentions earlier in the day.
Dr Sylvia Tang, Priory Group medical director, said: