Mental healthcare specialists missed five opportunities to complete suicide risk assessments on an 18-year-old girl in the three months before she was fatally hit by a train, an inquest heard today.

From Sep 30 2014: 'Caring' Croydon teenager and Sutton student dies at Wimbledon station hours after supporting friend over father's death

From June 2 2015: South London and Maudsley NHS Trust staff criticised after Croydon teenager Veronica Romero killed by train at Wimbledon station

Veronica Romero-Lopez, known to her friends as Ronnie, died at Wimbledon Station on September 22 last year. She said goodbye to a friend on the phone and climbed onto the tracks.

The Croydon teenager had been diagnosed with bipolar disorder shortly after the death of her father from cancer in her early teens and had tried to commit suicide three times between 2012 and 2014.

The day she died she had been helping another friend whose father had died.

When she was transferred from Croydon CAMS (children mental health services) to adult mental health services in June last year, no formal risk assessment or care plan was completed.

The meeting was not even recorded and there is no written documentation with details of what took place.

Speaking at the inquest at Westminster Coroners' Court today, clinical nurse specialist Katherine Delvin of Croydon CAMS, who was present at the 30-minute handover meeting said: "On reflection I wish I had updated the risk assessment."

The nurse had sent a letter to the adult mental health team detailing two of Miss Romero's previous suicide attempts, diagnosis and history of self harm.

But no formal risk assessment had been completed since she was discharged from Springfield Hospital in Tooting in February of that year.

Her new care co-ordinator at South London and Maudsley NHS Mental Health Trust Pauline Laforge, formerly a psychiatric nurse with 32 years experience in mental health, then failed to complete the risk assessment and care plan at four further meetings.

The care plan would have included a strategy of how to deal with crisis situations and a telephone contact for a mental health specialist she could have called, the court heard.

An audit of patient records carried out following Miss Romero's death found that only between 30 and 40 per cent of adult mental health patients in Croydon had care plans completed.

At least 80 per cent of those patients had received up-to-date risk assessments.

Ms Laforge told the court the care plan and risk assessment had not been completed due to her "high" case load of 33 patients.

Dr Clive Timehin, a psychiatric consultant who assessed Miss Romero on July 10 last year as of a moderate to high suicide risk, said he would have expected there to have been an up-to-date formal risk assessment and care plan in place.

But he said he believed Miss Romero was suffering from an emotional unstable personality disorder so even if those assessments had been in place, her death could not have been predicted or prevented.

On the evening she took her life, Miss Romero had gone to comfort a friend whose father had recently killed himself by jumping in front of a train at Mitcham Eastfields Station.

The friends argued and Miss Romero left the house and traveled to Wimbledon Station. She was on the phone to another friend when she jumped onto the tracks, said 'goodbye' and was fatally hit by a train.

Recording a narrative verdict, coroner Fiona Wilcox said: "I find on the balance of probabilities that she took her own life while suffering a severe and enduring mental illness."

She criticised the care co-ordinator for not completing assessments but said Miss Romero's death was neither "probable" nor "preventable".

She also said she was satisfied that Croydon mental health services have since addressed the problems in their department, by increasing staff numbers, limiting case numbers to 30 per staff member and organising a risk assessment training day.

Speaking after the inquest, Miss Romero's brother, Juan Romero, 26, said: "I hope that what happened to Veronica will be a lesson learned for future patients. That's all I care about."

The young woman was described in court as "beautiful, well-groomed, articulate and intelligent".

Friends and family were in court to hear the inquest.

In a statement released after the hearing, a spokesperson from South London and Maudsley NHS Foundation Trust said: “We would like to offer our sincere condolences to the family of Veronica Romero- Lopez. 

"We carried out an investigation and measures, such as employing more staff and ensuring all patients have an up to date care plan, have been put in place to ensure that we deliver high quality support to service users.”

For confidential support, contact Samaritans on 08457 90 90 90 or visit samaritans.org.