Inspectors say it still needs to improve how it investigates patient deaths - but is getting better.
Teenager Died After Chores Argument
A teenager threw himself in front of a train after arguing with his mother over his household chores, an inquest has heard.
Jack Wall died from multiple injuries after he was hit by the Portsmouth to London Waterloo service at Liphook railway station, Hampshire, on the evening of November 17 last year.
The inquest at Alton heard that the 18-year-old, who suffered from attention deficit hyperactivity disorder (ADHD), had fallen out with his mother, Tracy Wall, that day after he failed to complete his chores, including picking up her medication from the chemist.
The hearing was told that Mr Wall was born in the US but Mrs Wall had moved back to the UK with her son in 2004 when she divorced his father, Steve Wall.
They lived in Salisbury, Wiltshire, before moving to Portsmouth and then Liphook.
Mrs Wall told the hearing that she had told her son, who worked in the kitchen of the Old Thorns Manor Hotel in Griggs Green, to sleep at a friend's house that night as a punishment.
Sobbing as she gave evidence, she said: ''I decided Jack could do without some creature comforts for one night and he could sleep on someone else's sofa for the night.
''We had words but we didn't shout. I said 'Get out, get out, you are just like him (his father)'.
''I went downstairs, Jack came down and said 'Say goodbye to your son'.
''I said 'Bye Jack' and Jack left the house and that was the last I saw of him.''
Mrs Wall said she contacted his friends to make sure he had a bed to sleep on that night and tried to call him but did not hear anything until the police informed her of his death.
She added: ''Jack was a very loving person.
''I would describe our relationship as being a married couple without being a married couple.
''Jack was my world. Jack was a very loving, sensitive young man and he did get easily upset.''
Friend Luke Mees told the inquest that he had been at work that night until 1am and had not had mobile phone reception.
He said: ''Jack was always a lovely, cheerful person.
''He said he was having problems at college but he said that was all right now.''
He said that at 1.34am he then received a delayed message from Mr Wall speaking of troubles he had been having with his mother and saying he intended to take his own life.
The message said: ''It took me a long time to finally make this decision.
''I don't even know where to start!!! Let's start with saying I have suffered almost a decade of psychological abuse from my mum and I'm broken!!
''Years of being told 'You're just like your father!/You're a nobody!/I wish I had a better son!'
''I don't want to continue living after all that has happened in my life since coming to England.
''Watching your mum physically hurt herself and blaming it on you!
''That's what destroyed me!! I chose to entrust you with this message because I know you're the one who has chosen to stick by me through all my problems and I'm so sorry!
''I'm so sorry to the ones who care about me and more specifically you!
''I'm sorry for burdening you with everything and then just disappearing like this!
''I will look out for you from wherever people like me go.
''I have no more tears left to shed. If I did their ghosts would be falling.
''See ya whenever dude and try not to make too much of a fuss about it. People have their lives to get on with.''
Mr Wall's grandmother Eileen McGrath said: ''Jack never said anything to me about having problems at home.
''I can't believe it's true, they were so close and loving all the time.''
The inquest heard that Mr Wall had been taking the medication ritalin for his ADHD but had decided to stop taking this before starting his studies at Alton College.
His mother said that he wanted to join the Royal Navy which she said required recruits to be drug-free for three years.
She added: ''Prior to starting college he decided to stop taking his medication, he wanted to be himself and the medication took away his personality.''
The inquest jury of six women and two men returned a verdict of suicide.
North Hampshire Coroner Andrew Bradley expressed his condolences to the family.
Speaking after the hearing, Mr Wall's cousin Claire Sherwin said: ''We love Jack very much and we are sorry that we didn't know he was having any troubles, he could have come to any of us.
''His death is very sad and he's left the whole family very sad.
''It's a very sad day and we miss him very much.''
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