A teenager who died after taking too many painkillers had been prescribed the pills despite two recent overdoses on the same medication, an inquest has heard.

Ellie Knight, 19, was given a month’s supply of an anti-inflammatory drug to manage back pain by a GP who later conceded with hindsight that he “should have given her less”.

The animal lover overdosed on the pills a fortnight after receiving her prescription and suffered a cardiac arrest and severe brain damage.

She was rushed to Margate’s QEQM Hospital but tragically died three weeks later on January 9 this year.

Her family have now questioned why she was given such a large supply of the pills within two months of three previous overdoses - two of them involving the same painkiller.

An inquest into her death was told Ellie had gone to Newington Road practice in Ramsgate on December 4 last year complaining of back pain.

GP Dr Geoffrey Kimanje believed seizures suffered in a separate overdose just a week earlier had led to inflammation in her joints, and there were suspicions she had hypermobility issues.

The hearing was told Ellie’s mother, Sarah Knight, was said to have been “angry about the doctor prescribing” a month’s worth of the medication as she had reportedly requested her daughter not be given the drug.

However, Dr Kimanje told the coroner he had been left with a difficult decision and had spoken to Mrs Knight – who did not attend the inquest – before issuing the prescription.

The GP said he did not recall any opposition, adding that he even made an agreement with Ellie and Mrs Knight that the teenager’s medication would be administered by her mother.

“I thought [the drug] was the best option for anti-inflammatory [issues]. I thought I’d get her something more restrictive in terms of it needing a prescription,” he told the hearing.

“I think it’s easy to say she should have had less tablets, but I didn’t want to be obstructive in her care.

“I took confidence in [the family]; in hindsight, I should have given her less.”

Despite the reported agreement, it was not made clear how or why Ellie had come to administer the drugs herself, though there was no suggestion her family were at fault.

When asked if there was anything he felt he should or could have done differently given the circumstances at the time, the GP said: “I don’t think so.”

The inquest heard Ellie had admitted to having thoughts of suicide since the age of 11 and had been under the care of mental health services.

Her family expressed concern that a reported promise of home visits they thought would be daily did not materialise, with Ellie visited just once by mental health teams.

But Kirsty Wade, an operational manager at the Kent and Medway NHS and Social Care Partnership Trust (KMPT), said no such offer should have been made and would not even have been possible in Ellie’s case, due to her often spiralling at night when home visits do not take place.

It was explained that Ellie did not engage particularly well with other mental health teams and the view at the time was that daily visits could have actually increased the risk of Ellie acting on the commands of “derogatory voices” in her head.

“It was quite a complex picture,” said Mrs Wade.

“She'd been staying up late at night and had a poor structure but there was evidence of futuristic thinking and planning.

“She was also reluctant to utilise service contact numbers for support, as she didn’t like burdening other people with her problems.

“The risks were low enough that we could have managed them in the community, but she still potentially could have needed some extra support.

“She didn’t seem to have any coping strategies for when she was stressed.”

As well as the expected home visits falling through, it was explained that a psychiatric appointment had to be cancelled due to Ellie being in hospital following one of her overdoses. She died before it could be rearranged.

Coroner Catherine Wood said Ellie had sought help following her three previous overdoses.

She said at the time of the fourth, on December 18, it was not clear what Ellie’s intentions were.

Delivering a narrative conclusion at the hearing in Maidstone on Friday, she expressed her condolences to Ellie’s family and explained why she could not rule her death a suicide.

“She was referred for a programme of psychological treatment which she sadly didn’t receive because of her death,” said Mrs Wood.

“I cannot say whether her being on that pathway would have changed the eventual outcome.

“We don’t have any evidence to suggest she wanted to die. I don’t have evidence she didn’t intend to die.

“We don’t know the facts – we weren’t there.

“[Dr Kimanje] gave the reasons for his prescription of Nefopam. I accept his evidence on this point. He also rang Ellie's mother at the time of the consultation.

“Whilst I accept the evidence that we did hear, it may have been better to have a plan in relation to medication in the risk assessment process as part of a risk assessment at the mental health services.

“As coroners we see too many deaths of young people who die as a consequence of their own actions.

“It's something that in this world we do see more than any of us would like to, but it's very difficult for staff in a mental health setting to assess the risks here as to what can be done.

“I'd note that there is work to be done in terms of risk assessment and work has been undertaken and there have been reorganisations of services.”

Mrs Wood added she would not be making a Prevention of Future Deaths Report, with mental health teams already undergoing changes in staff training and guidelines in response to recent events.

Ellie’s parents believe she did not intend to take her own life and previously said they wished she had accepted just how loved she was by everyone.

“We don’t think she did it to end her life, or to get to the point it got to. It was a cry for help, but we can’t change anything,” they said.

“She had such a big heart, and was loved by so many people - more than she knew. We told her lots but she just didn’t accept it.”

“Ellie did suffer from depression, she did have worries, and it played a big part in what happened.”

Born on June 14, 2004, Ellie was the middle child of three siblings, with 22-year-old Liam and five-year-old Robin completing the household.

The former Broadstairs and Canterbury College pupil aspired to work in animal or childcare, having a fondness for both, and studied health and social care.

A keen music lover with a wide range of tastes, she was also an avid watcher of TV, with Friends and Victorious among her favourite shows.

As an adult, Ellie developed an interest in motorbikes and had planned to buy one to do up with her dad, Michael.

For confidential support on an emotional issue, call Samaritans any time on 116 123.