A coroner has criticised a troubled mental health trust for failing a teenager who took his own life.
Nyall Brown, 19, from Cromer, died in May 2018.
Norfolk coroner Jacqueline Lake said she had concerns over staff not reviewing his care records before appointments, which would have enabled more accurate assessments.
The Norfolk and Suffolk Foundation Trust said it was “introducing learning sessions” focusing on preparation.
Ms Lake has written a Prevention of Future Deaths report to the trust, asking it to take action to protect others.
“This is a matter which has been raised with the trust previously,” she said.
“Staff are expected to read previous records relating to a service user, but this is not always happening.”
She added: “Evidence was heard that Mr Brown’s care records were not reviewed prior to his being seen, which would enable Mr Brown’s full history and risks to be taken into account when assessing him.”
NSFT is the only mental health trust to have been put in special measures, and in November was rated ‘inadequate‘ for a third time.
Mr Brown’s parents Tracey and Mearl have been critical of the service, describing their dealings with the trust as “inadequate, poor and shocking“.
They first sought help after their son attempted to take his own life in January, but at one point were advised to seek private medical help.
Diane Hull, chief nurse at NSFT, said a detailed review had been conducted into the events leading to Mr Brown’s death, and was being acted upon.
“This includes looking at the interface between wellbeing and secondary mental health services and our crisis teams, and strengthening clinical leadership,” she said.
“In addition, we are introducing learning sessions which focus on documentation, communication and the importance of preparation ahead of appointments.”