A 16-year-old boy's death has prompted a review of how patients are referred by GPs to mental health services in Suffolk.
The parents of James Sutton, from Ipswich, paid tribute to a "wonderful young man" and model pupil following an inquest into his death on Tuesday.
He died on March 31 2021, a few days after telling his GP he had thoughts of self-harm and concerns for his mental health.
The Copleston High School Sixth Form student's GP at Orchard Medical Practice referred him to Suffolk Emotional Wellbeing Hub (EWH) as an urgent case that needed to be seen within 72 hours.
The wellbeing hub, run by Suffolk County Council and Norfolk and Suffolk NHS Foundation Trust, downgraded the GPs’ recommendation as it claimed there were not enough details from Doctor Senthil Vivek, who had his receptionist fill out the form.
The court heard there were not enough clinical details and James’ parents and school's contact information was left off the form.
EWH sent a text to James without speaking to him, his GP or his parents saying his treatment had been downgraded so he would be seen within 28 days.
After an NSFT investigation, reforms were made that required the EWH to always call parents, and in most cases the child and their GP after a referral.
A new form is to be given to GPs and guidance put in place on how to fill it out.
James’ parents told the court that the reforms did not go far enough to prevent the deaths of more young people.
His mum Sabine Sutton said: “You wasted precious hours and minutes.
“[The service] seems very confusing and layered and was not truly robust and I’m still concerned about future boys and girls.
“It still seems very unclear to me and I still do not understand why James was not seen sooner.
“Where was that trained, skilled person for James?
“I find it shocking and concerning for other children.”
Mrs Sutton also criticised Doctor Vivek for not speaking to her as she requested when she put James on the phone to have his initial consultation in March 2021.
“You’re expecting a 16-year-old boy to explain more and he’s never met you and hasn’t seen your face," she said. “You’re basing it on very little.
“You put James at risk and denied me parental autonomy. I did not know he had thoughts of self-harm. Why did you not speak to me?”
Mr Vivek told the court: “I asked to speak to James’ mum again and he informed me she was in the [garden] and would inform her what happened.
“He had no active suicidal thoughts. And on that basis, I decided to respect James’ decision.”
He said “on reflection” he would have called the emotional response team, filled in a crisis form, asked more probing questions and brought down the referral to four hours.
But he claimed he was using the General Medical Council’s guidance that does not call for urgent action when there are no “active feelings of suicide”.
Katie Hall, a mental health nurse and community team manager at EWH, said: “The procedure at the time was followed.
“I think if we had had a conversation, we could have found out more information around his mental state.
“If someone is 18 or under, we would always speak to the parent or guardian.”
Kevin Beardsworth clinical director from NSFT admitted it was a “missed opportunity” and the GP was in a “difficult situation”.
Mr Beardsworth said mental health services are “limited” by the number of staff and long waiting lists at the trust.
“You can still approach parents for information and what is their sense of what is going on," he said.
“There is now a lot of guidance about what information we need from GPs and what kind of questions and what needs explaining.”
Geoffrey Sutton, James's dad, said: “We have really got to put children first.
“That really ought to be in big bold letters.”
Suffolk coroner Jacqueline Devonish gave a narrative verdict saying James “took his own life” due to “acute mental instability” after being referred by the GP for support.
He died in Addenbrooke’s Hospital after a fall from Spring Road Bridge in Ipswich, she added.
“This was a young man, doing well, at sixth form, looking forward to university,” she said. “The kind of young man any parent would have been proud of.”
Mrs Sutton told the court: “He was a really determined, independent boy, as well as musical and caring.
“He worked really hard and was working at his A-levels and making plans for the future and to go to university.”
Mr Sutton said he was a “wonderful young man” and a “model pupil”, whose whole peer group “looked up to him”.
DCI Steve Duncan, of Suffolk police, said: “James was a very intelligent and articulate young man and tried to handle the issue and used models and ways of dealing.
“There was no indication he wasn’t dealing with it.
“He tried to sort it out himself and couldn’t."
If you need help and support, call Norfolk and Suffolk Foundation Trust’s First Response helpline 0808 196 3494 or the Samaritans on 116 123. Both services are available 24 hours 7 days a week. You can also download the Stay Alive app on Apple & Android
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