Rosamund Rhodes-Kemp made the comments at the end of an inquest into the death of Moon Flower, 18, who jumped from the top of a multi-storey car park in Kingsbridge Lane, Southampton.
Moon had been taken to University Hospital Southampton (UHS) two months earlier after threatening to leap from another car park – but was discharged.
The inquest heard that the teen had previously jumped in front of a moving vehicle in Dorset.
But Mrs Rhodes-Kemp said there was little evidence that any information about her was passed on after she moved from Bournemouth to Southampton.
She also said UHS staff could not access – and did not request – Dorset’s data on Moon’s medical history when they saw her in June 2024.
Moon Flower took her own life two months after being discharged from University Hospital Southampton after threatening to take her own life (Image: Newsquest)
Mrs Rhodes-Kemp said Moon’s decision to relocate resulted in the cessation of all the support and treatment she had received in the past.
Weeks after being discharged from the A&E department at UHS, the teenager ended her life after splitting up from her boyfriend.
She was also worried about the prospect of having to leave her sheltered housing at Gordon Avenue, Southampton, as a result of turning 18, the Winchester inquest was told.
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Using a camping analogy, Mrs Rhodes-Kemp said all the pegs securing Moon’s tent had disappeared “one by one”.
In a statement read to the inquest by the coroner, her family said: “Moon was a force of nature. Everything she set her mind to she achieved. She was an artist and a writer – someone who created things.
“Her true love was music. She would sing all day. It’s hard to believe we will never hear her voice again.”
An inquest into the death of 18-year-old Moon Flower was held at Winchester Coroner’s Court (Image: Newsquest)
Witnesses attending the hearing via video link repeatedly wiped away tears as the coroner read the tribute before adding one of her own.
“The world wasn’t meant for someone as beautiful as Moon,” she said.
Dee Dilworth, manager of the housing scheme where the teenager lived, described her as “human sunshine”. Another witness added: “She was a very bright light and the world is not a great place without her.”
Moon died in the early hours of August 18 2024. Mrs Rhodes-Kemp recorded a conclusion of suicide.
University Hospital Southampton NHS Foundation Trust and Dorset HealthCare University NHS Foundation Trust have been contacted for comment.