- Video report by ITV News Correspondent Chris Kiddey
The parents of a student found dead at her halls of residence have said she was "failed" by mental health services.
University of Liverpool student Ceara Thacker, 19, was found dead in her room in the Brownlow Hill accommodation on May 11 last year.
The five-day inquest at the Gerard Majella Courthouse in Liverpool heard her family was not informed she had taken an overdose three months before her death, or that she was struggling with her mental health.
Speaking outside the court on Friday, her father, Iain Thacker, 56, said: "For as long as I live I will never understand why no-one at the university picked up the phone to us in February 2018, and told us that our 19-year-old daughter was in hospital after taking an overdose.
"If we had known how Ceara was suffering we could have, and would have, made a difference."
He said his daughter, from Bradford, had found herself "falling through the cracks" with different mental health services, who failed to communicate with each other.
He added: "In my view it is absolutely essential that all universities have in place proper systems for identifying students at risk and communicating effectively with healthcare services and, where appropriate, with families, to ensure they are kept safe."
Her mother Lorraine Dalton-Thacker, 51, said: "At every turn, she was failed.
"I can't imagine how frightening that must have been for her. She should not have had to face this and it breaks our hearts that she did.
"We don't want any other family to go through this pain."
Recording a conclusion of suicide, area coroner Anita Bhardwaj said she would make a report for the prevention of future deaths to the NHS, recommending that the issue of parental involvement, with consent, was included in mental health assessments.
She said: "It's difficult and unclear whether Ceara would have had a different outcome had she had additional mental health appointments, been given an urgent appointment, and had family involvement."
Ms Bhardwaj said there was no record of discussions between medical professionals and Miss Thacker about contacting her family.
She said: "It would have been helpful to have those discussion, so if Ceara wanted additional support from her family that could have been facilitated.
The coroner described a delay of two months between Miss Thacker referring herself to the university's mental health advisers in February, and being given an appointment in April, as "unacceptable".
Gavin Brown, pro-vice-chancellor for education at the University of Liverpool, said: "We have conducted a thorough review of the support Ceara was offered and, as a result of this and our ongoing review of how these services work, we have instigated a number of improvements to mental health support services."