BBC News
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image copyrightChris Shotton
image captionSam Gould (left) died in September 2018 and her twin sister Chris died four months later
A coroner has said systemic weaknesses and failings in communication between healthcare agencies probably caused the death of a 16-year-old.
Sam Gould took her own life with an overdose of prescription drugs in Fulbourn, Cambridgeshire in September 2018.
Coroner Nicholas Moss QC said there were shortcomings in her case.
An inquest for Chris Gould, Sam s twin sister, who died in January 2019, will take place next month.
The inquest at Huntingdon Town Hall heard that the twins had loving parents , and that Sam was an accomplished horse rider who was described as funny, kind, sassy and irreverent .
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