The death of a "vulnerable" transgender teenager who struggled to get help was preventable, a coroner has said.
Daniel France, 17, was known to Cambridgeshire County Council and Cambridgeshire and Peterborough Foundation Trust (CPFT) when he took his own life on 3 April 2020.
The coroner said his death showed a "dangerous gap" between services.
When he died, Mr France was in the process of being transferred from children and adolescent mental health services (CAMHS) in Suffolk to adult services in Cambridgeshire.
The First Response Service, which provides help for people experiencing a mental health crisis, also assessed Mr France but he had been considered not in need of urgent intervention, the coroner's report said.
Cambridgeshire County Council had received two safeguarding referrals for Daniel, in October 2019 and January 2020, but had closed both.
"It was accepted that the decision to close both referrals was incorrect", Mr Barlow said in his report.
Mr Barlow wrote in his report, sent to both the council and CPFT: "My concern in this case is that a vulnerable young person can be known to the county council and [the] mental health trust and yet not receive the support they need pending substantive treatment."
He highlighted Daniel was "repeatedly assessed as not meeting the criteria for urgent intervention" but that waiting lists for phycological therapy could mean more than a year between asking for help and being given it.
"That gap between urgent and non-urgent services is potentially dangerous for a vulnerable young person, where there is a chronic risk of an impulsive act," Mr Barlow said.
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Source: BBC News, 25 February 2022