Teenager’s death prompts

cannabis to make themselves aware of the risks and of ways to reduce that use.

The 14-year-old, whose name is suppressed, died in 2019. He had attempted suicide twice in the previous 18 months.

When he was about 4, the boy was referred for paediatric and psychiatric assessment over behavioural concerns, and suspicions of foetal alcohol syndrome and ADHD. It found him to be a ‘‘normal, energetic young boy’’.

In 2013, a further psychiatric assessment following disruptiveness at school found he was inattentive, hyperactive and impulsive. Records suggested the boy was a ‘‘fairly straightforward kid’’ until about 2016, when he became increasingly moody and defiant.

He was never formally diagnosed with a disability or mental health condition but received regular counselling.

On the day of his death, he had a half-day at school, so decided to stay home. That afternoon his girlfriend told him in a series of text messages that she did not feel in a position to continue their relationship. The teen twice texted he was going to kill himself.

She asked him not to do ‘‘anything stupid’’. About an hour later his adoptive mother asked if he would like to go into town with her. Upset, he told her did not want to and she left him in his bedroom.

While she was out she was contacted by one of his friends who was worried he might hurt himself. She immediately returned home where she found the teen dead. Police noted a smell of cannabis in a shed at the property, while in his bedroom were various cannabis-related items.

The mother told police she was aware he smoked cannabis and she had told him she preferred he did so in their shed, rather than out on the street. There was no evidence as to the frequency of his cannabis use. Clinicians who treated the boy noted his birth mother had experienced difficulties with cannabis and alcohol.

The coroner said there was no