A ‘brilliant’ young artist’s death could change how the NHS treats student mental health.

Becky Marshall died by suicide just weeks after starting university, in November 2017 – one of several student deaths in recent years.

Assistant Southwark Coroner Briony Ballard said there were ‘many missed opportunities’ in treating the Kent 19-year-old, as NHS trusts promised to learn lessons from her death.

The history of art student’s parents say that when she went to Goldsmiths University in London, she ‘fell in the cracks’ between two trusts.

An investigation and action plan by both the Lewisham and Kent NHS trusts pledged to increase communication, especially with students and high-risk patients.

A spokesperson for South London and Maudsley NHS Foundation Trust said: ‘Following Rebecca’s death, an internal investigation was carried out. We have identified areas where we can improve communication and information sharing with other Trusts and organisations, including universities, involved in a patient’s care.’

Parents Stephen and Jeanette Marshall, 59 and 57, found out daughter Ms Marshall was one of 80 people seen regularly by an overwhelmed mental health nurse in their hometown of Maidstone.

Inderjit Randhawa, the nurse at Kent and Medway NHS Trust’s primary care mental health team, said she should have been more proactive when dealing with the teen.

In the nine months before her death, she was left stranded as she attempted to get an in-depth appointment to discuss the dosage of her medication, which she felt was not working.

In July 2017, she attempted to take her own life before members of the public intervened – but still did not get an appointment or diagnosis to help manage her mental health.

Two months later, during a meeting with a mental health worker, she was accidentally told that experts had suggested that she could have emotionally unstable personality disorder, a controversial diagnosis in the UK.

Despite a concerning appointment in September 2017, when Ms Marshall said she imagined her self-harm wounds on her arm transforming into gaping mouths, there was another two-month wait for an appointment, because her need was ‘downgraded from urgent to routine’.

She then moved to London and repeatedly tried to get an in-depth appointment with the South London and Maudsley NHS trust.

Dr Nighat Yasmeen, who was the last doctor to see her on 8 November 2017, said that an error meant she was only seen for 20 to 30 minutes when the appointment should have taken an hour-and-a-half.

That meeting was supposed to be an in-depth discussion about her mental health but ended up being a medication review.

She died just two weeks later.

Helen Greatorex, Chief Executive of Kent and Medway NHS and Social Care Partnership Trust, added: ‘Miss Marshall’s death was a tragedy and we, along with our South London and Maudsley colleagues have committed to a series of actions.

‘We have strengthened our approach to supporting people who seek help through their GPs as part of our primary care services. Our aim is to make it as quick and easy as possible for people to get the help they need, when they need it.

‘We are working much more closely with the student wellbeing and support services in the colleges and universities across the county, with an emphasis on fast tracking students to the mental health help and support they need.

‘Our third key change is a county-wide, Public Health led, Suicide Prevention Project. This work has been nationally recognised and is something that we believe is already saving lives and will continue to do so.’

Ms Marshall was seen as a talented and determined artist, photographer and dancer.

Ian Bottle, her tutor during a foundation year at the University for the Creative Arts, Canterbury, said she made the most ‘profound impression’, adding: ‘Her sensitivity, ambition, intelligence and determination in her work were extraordinary and enabled her to realise the most moving final project.’

The evening before she died, Ms Marshall sent her father a text message to say that she loved him, her mother, and younger sister Katy.

The next day he called and messaged her several times, before using the Find My iPhone function to track her to her room, where her body was discovered.

He said: ‘We would like community trusts (and) primary care trusts to look at young people holistically.

‘If a person is moving, treat them as a person. There has to be checks, balances, follow-ups and communication between the home NHS trust and the trust they are with at university.

‘If you keep passing it down the line, you don’t take accountability. You throw the ball up and there’s no checks to see if someone’s actually caught it.

‘But that ball isn’t a ball, it’s a person. It’s a daughter or son or brother or sister.’

Mum Mrs Marshall also said universities have a responsibility to warn students if they do not have the ability to care for people’s mental health.

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