Molly Wilkinson was a happy child who did well in school and was popular with her peers.

But at the age of 14, her life fell apart.

Anxiety, depression, self-harming and suicide attempts all stemmed from Molly’s feeling of complete worthlessness.

“She was supposed to have had the support she so desperately needed from the Mental Health Services, but it never happened,” her father, John Wilkinson, told Pembrokeshire coroner’s court. 

“And there were periods when she received no care at all. 

"Some of the medical professionals were horrible to her, and one even told her there was nothing wrong with her. 

"Another told her not to contact the Crisis team after she had been removed from their register even though she needed their help.”

At the age of 19, Molly Wilkinson, of Yorke Street, Milford Haven, took a drug overdose that resulted in death from multiple organ failure.

This week Pembrokeshire senior coroner Mr Paul Bennet was told repeatedly by health workers, including Pembrokeshire Crisis Team’s consultant psychiatrist Dr Maria Atkins and Crisis Team mental health nurse Elizabeth Robinson, that Molly should have been given the support of a care co-ordinator during her transition from the Child and Adolescent Mental Health Services to the Adult Mental Health Services  at the age of 18. 

The care co-ordinator would have overseen Molly’s complex transition process, however staff shortage issues at the time prevented this from happening.

The consequences of this failure were summed up by Professor Kevin Gournay, a registered psychologist and Emeritus professor at the Institute of Psychiatrists, King’s College, London.

“Had a register been in place (for Molly) and had someone been responsible for maintaining that link, things would have been very different,” he told the inquest.

"Molly was picked up in periods of crisis but there was nothing in between.

"If this had happened, the risk would have been significantly mitigated.”

Recording a verdict of misadventure, coroner Paul Bennett chose not to write a Regulation 28 Report which would identify causes for preventing future deaths from happening in the same way, citing the fact that Molly had received appropriate care from the individual health workers who had worked alongside her.

“There is no guarantee that there wouldn’t have been a repeat scenario,” he said. 

“Had a care co-ordinator been in place, it would have mitigated the risk  but not removed it entirely.  I’m hopeful that a situation such as Molly’s won’t arise again.”

The verdict was clearly a disappointment to Molly’s parents.

“I disagree with the conclusion that appropriate care was given to Molly,” said John Wilkinson.

“The only time she came under their radar was when she was in crisis.  But once the crisis was over, there was nothing. The team failed her.”