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The suicide of a "brilliant" young artist could forever change how the NHS treats mental health cases involving students.
Becky Marshall, from Maidstone, took her own life just weeks after starting university - repeating a pattern of several similar deaths in recent years.
A policeman's daughter, she was just 19-years-old when she overdosed on medication hoping to find peace from the voices in her head telling her to end her life.
Her parents say when Becky went to Goldsmiths University in London to study the History of Art, she "fell in the cracks" between two NHS trusts.
Assistant Southwark Coroner Briony Ballard has filed a report to prevent future deaths.
She said there were "many missed opportunities" in Becky’s treatment that may have prevented her suicide, in November 2017.
Stephen and Jeanette Marshall found out daughter Becky was one of 80 people seen regularly by an overwhelmed mental health nurse in their hometown of Maidstone.
Inderjit Randhawa, the nurse at the primary care mental health team with Kent and Medway NHS Trust, said with hindsight she should have been more proactive when dealing with Becky's health.
In the nine months before her death, Becky was left stranded as she attempted to get an in-depth appointment as she felt her low dose of citalopram was not working.
In July 2017, Becky tried to take her life by climbing onto the wrong side of a barrier on a bridge in Kent.
After passers-by spotted her, she was restrained and taken to hospital.
But this was not enough to get the appointment she badly needed and a diagnosis that would help her manage her mental health.
During a meeting in September with a mental health worker, Becky was accidentally told a doctor had diagnosed her with emotionally unstable personality disorder, also known as borderline personality disorder.
A GP and psychiatrist listed EUPD as a possibility in their notes, although this was never explicitly an official diagnosis.
Emotionally unstable personality disorder is a controversial diagnosis in the UK.
Some doctors are hesitant to diagnose it, especially in the cases of young women who make up the majority of patients.
Other medical experts also say you should not diagnose anyone younger than 25 with a personality disorder as their personality is still developing.
Despite a hugely concerning appointment in September 2017, where Becky said she imagined her self-harm wounds on her arm transforming into gaping mouths, there was another two-month wait for an appointment.
Inderjit said this was because her appointment need was downgraded from urgent to routine.
She said: "Becky clearly had a supportive and loving family. She seemed excited, if nervous, about going to university.
“The community health team also said they were at capacity, and thought if she needed regular in-person care, it was best for her to be in primary care."
Becky moved to London and repeatedly tried to get an in-depth appointment with the South London and Maudsley NHS trust.
Dr Nighat Yasmeen, who was the last doctor to see Becky on 8 November 2017, said an error meant she was only seen for 20 to 30 minutes when the appointment should have taken an hour-and-a-half.
That appointment was supposed to be an in-depth discussion about her mental health but, instead, it was just a medication review.
Just two weeks later, Becky killed herself.
The day before she died, Becky sent her father a text message at 10.30pm to say that she loved her father Stephen, mother Jeanette, and younger sister Katy.
The next morning when Stephen woke, he called and messaged her several times throughout the day. It was out of character for her to not respond.
In the evening, he used the Find My iPhone function and was able to track Becky to her room.
At 8pm, concerned Stephen went to Goldsmiths and spoke to night duty manager Shajait Hussein.
He asked a female assistant to enter Becky's room and it was in darkness.
The body of the 19-year-old was cold underneath the duvet, and her arm was stiff and turning blue.
Shajait said: "I shook her gently, and the arm felt very cold and there was foaming at the mouth.
"Her sensitivity, ambition, intelligence, and determination in her work were extraordinary... she will be greatly missed" - Ian Bottle
"I realised Rebecca must have been deceased."
Paramedics and police attended the scene and pronounced the time of death at 10.39pm.
A suicide note was discovered, which was not read at the inquest, but it was said it described "much love for both her parents".
Sergeant Thompson ruled it at the scene as a non-suspicious death, and also handed the case to the coroner's office.
Becky's father Stephen Marshall, 59, said: “We would like community trusts, primary care trusts to look at young people holistically.
“If a person is moving, treat them as a person. There has to be checks, balances, follow-ups and communication between the home NHS trust and the trust they are with at university.
“If you keep passing it down the line, you don’t take accountability.
"You throw the ball up and there’s no checks to see if someone’s actually caught it.
“But that ball isn’t a ball, it’s a person. It’s a daughter or son or brother or sister.”
Jeanette Marshall said universities also have a responsibility to warn students if they do not have the ability to care for people’s mental health.
The 57-year-old said: “Universities have a responsibility to say we can’t care for you, if they can’t.
"They should maybe say you should get help before you come here before the stress and the pressure."
Stephen also said: “It’s not a question of a cure. It’s managing risk and circumstances and making sure they have the best possible life.
“It’s working out what’s the best possible path for them rather than putting them in the ‘too difficult’ box.
“It’s a question of resource and of being open and honest and treating people holistically.”
Becky was a talented and determined artist, photographer and dancer.
A teacher once told her parents her work could be submitted to a Tate Portrait Gallery competition, but she was unable to enter as she was too young.
Ian Bottle, Becky's tutor who worked with her during her foundation at the University for the Creative Arts, Canterbury, said she made the most "profound impression".
He said: "Her sensitivity, ambition, intelligence and determination in her work were extraordinary and enabled her to realise the most moving final project.
"She will be greatly missed."
Assistant Coroner Ballard also said: "I offer my condolences to you Mr and Mrs Marshall.
"Becky was clearly a brilliant and talented lady."
An investigation and action plan by both the Lewisham and Kent NHS trusts pledged to increase communication especially in regards to students and high-risk patients.
Both NHS trusts connected to Becky have vowed to change to stop her death from being in vain.
It is in a desperate attempt as the suicide rate in the UK has risen for the first time since 2013, according to the Office for National Statistics.
A significant rise was seen among young girls and women aged 10 to 24 in the last year.
A spokesperson for South London and Maudsley NHS Foundation Trust said: “We offer our sincere condolences to the family and friends of Miss Rebecca Marshall.
"We are so sorry that Rebecca's young life was lost to suicide... we are committed in Rebecca's memory to making and sustaining the changes we have outlined as well implementing any others recommended by the coroner" - Helen Greatorex
“Following Rebecca’s death an internal investigation was carried out.
"We have identified areas where we can improve communication and information sharing with other Trusts and organisations, including universities, involved in a patient’s care.
"The coroner was satisfied with the improvements the trust has made.”
Helen Greatorex, chief executive of Kent and Medway NHS and Social Care Partnership Trust, said: “Miss Marshall’s death was a tragedy and we, along with our South London and Maudsley colleagues have committed to a series of actions, linked to HM Coroner's findings and our own reviews in to what could and should have been better in her care.
“We have strengthened our approach to supporting people who seek help through their GPs as part of our primary care services.
"Our aim is to make it as quick and easy as possible for people to get the help they need, when they need it.
“We are working much more closely with the student wellbeing and support services in the colleges and universities across the county with an emphasis on fast tracking students to the mental health help and support they need.
"Our third key change is a county-wide, Public Health led, Suicide Prevention Project.
"Kent and Medway was one of four areas in the country to be awarded additional specialist funding to find ways of getting to people before they reach the point of considering suicide.
"This work has been nationally recognised and is something that we believe is already saving lives and will continue to do so.
"We are so sorry that Rebecca’s young life was lost to suicide and we know that the tragedy of her loss will be something with which all those who loved her will now always live.
"We are committed in Rebecca’s memory to making and sustaining the changes that we have briefly outlined here as well implementing any others recommended by HM Coroner."
Following Becky's death, father Stephen's former team at Maidstone Police station climbed the three peak challenge in Wales in July last year.
They raised just shy of £4,000 for Young Minds, a charity working to improve the mental health of children and teenagers.
Anyone in need of emotional support is urged to call the Samaritans on 116 123.
Kent County Council's Release the Pressure campaign also urges people to call 0800 107 0160 where support is available from trained and experienced mental health staff, 24 hours a day 365 days a year. For more information click here.
