REPEATED recommendations to refer a young boy to mental health services went unheeded by social services, an inquest has heard.

Today (Thursday), an inquest resumed into the death of Pembroke schoolboy Derek Brundrett.

Coroner Paul Bennet heard from social services expert Vic Citarella, who said there had been 'professional failures' in the case of the 14-year-old, who was found hanged at school in December 12, 2013.

Gaps in record keeping by social workers, a lack of communication between social services and education teams, and confusion over the responsibilities of various departments have also come to light.

Despite concerns about Derek’s emotional state, 'worrying behaviour' and talk of suicide and self harm, social services did not refer Derek for a mental health assessment with the Specialist Child and Adolescent Mental Health Services (sCAMHS).

Two referrals were made on his behalf, one in 2012 by a GP nurse, and one in 2013 by a GP, but both were declined as Derek was not seen to meet the necessary criteria.

Mr Citarella said he believed the latter referral had been made "out of frustration”.

"I feel that the GP did this because no-one else had, and it had gone round the houses a bit and no-one had actually said 'yes, let's do this',” he added.

The court heard that on at least two occasions, the advice given to social workers was to seek referral for mental health assessment.

Mr Citarella said there was evidence of effective systems being in place within the local authority, but these protocols had not always been followed.

Lorna Mayer QC, representing Pembrokeshire County Council, asked whether it was acceptable for social workers to use other methods - such as a phone call or letter - to seek referral, instead of the official form used sCAMHS.

Mr Citarella said these were available alternatives, but questioned why a service would go to the trouble of having a protocol only to then deviate from it.

He said social workers had 'made a potentially reasonable and potentially right decision' about not referring Derek for mental health assessment, but had "done it the wrong way" by not recording their decision in Derek's file.

"As a social worker I was always taught if you use an alternative mechanism you should always explain why," he said.

"If you deviate from procedures it needs to be defensible."

Sarah Clarke QC, speaking on behalf of Hywel Dda Health Board, said as far as sCAMHS was aware, the local authority was well-informed about the protocol for making referrals.

She said training had taken place to make sure both agencies knew the pathway existed.

Mr Citarella also said it was unclear why, in the months before his death, the priority for Derek's direction of care was switched from seeking mental health assessment to seeking referral to a community paediatrician to look at Derek's behavioural issues.

The inquest is expected to conclude tomorrow (Friday).