FAILED
Damning report says girl, 14, who took her own life was let down by mum, social workers and mental health service
A DAMNING report into the death of a troubled teenage girl has found ‘more could and should have been done’ to help her.
Charlotte Baron, 14, was found hanged in her bedroom at her home in Falinge, Rochdale, in February 2016.
The St Cuthbert’s High School pupil, who was known to social services and was being seen by a mental health worker, had been selfharming.
Prior to her death she had tried to take her own life to two separate occasions.
Now a Serious Case Review (SCR) published today by Rochdale Borough Safeguarding Children’s Board has found that Charlotte was failed by the people she relied upon – her mother, social workers and her mental health worker – at that time when she needed them most.
HOME LIFE
The daughter of an alcoholic mother and an abusive father, Charlotte suffered a chaotic and troubled upbringing.
As a young child she was ‘exposed to serious and persistent domestic abuse and the separation of her parents,’ the SCR said.
By the time she reached the age of seven, police had been called to 10 reports of domestic violence at the home, the majority of which resulted in Charlotte’s mum Veronica Kilbride being injured by her dad, who was eventually jailed for the abuse.
During her life Charlotte moved home ‘about 27 times.’
And the review said she had been self-harming since year seven at school and was extremely unhappy at home, which often had no food, heating or electricity.
She suffered a difficult relationship with her mum, who regarded Charlotte’s suicide attempts and selfharm as ‘attention seeking,’ and often expressed a desire to move out of the family home, telling her mental health worker she wanted to live ‘somewhere where she feels looked after’ .
But when social services tried to help the family, Ms Kilbride was often ‘reluctant to engage’ or failed to show up for meetings.
SOCIAL SERVICES
Social workers from Rochdale council were assigned to Charlotte following her first suicide attempt in September 2015 when she took an overdose of paracetamol and ibuprofen tablets. The review found her main social worker had just one year’s experience and needed ‘consistent management support.’ But despite this, and a realisation that Ms Kilbride was a ‘very difficult client to work with,’ the review found ‘management oversight of this case was poor’ and there was a ‘gross naivety’ in social services’ belief that Charlotte’s mum would tackle her drinking problem. The social worker’s description of Charlotte’s death as a ‘shock’ was also described as ‘out of step with the reality.’
MENTAL HEALTH SERVICES
Charlotte was also being seen by a mental health worker from Pennine Care NHS Trust’s Child and Adolescent Mental Health Services (CAMHS) team, who considered the teen to be at ‘high risk’ of self-harm.
The mental health worker was
She was exposed to serious and persistent domestic abuse and the separation of her parents Serious Case Review
said to be ‘extremely concerned’ about Charlotte and expressed frustration that ‘something should have been done.’
But despite the concerns, no one from CAMHS attended any of the multi-agency ‘Child in Need’ meetings which were held to discuss Charlotte and her family’s case.
The mental health worker, said to be an ‘experienced practitioner,’ was also criticised for not making a ‘robust challenge’ to social services when she felt Charlotte’s needs were not being met.
Standards of record-keeping in CAMHS were also found to be fallen ‘much short of agency standards.’
CONCLUSIONS
The Serious Case Review panel found social services and the Child and Adolescent Mental Health Services ‘both accepted that more could and should have been done to support and listen to’ Charlotte.
The panel has recommended ‘as a matter of urgency’ that all children assessed as being at medium or high risk through self-harm are referred directly to children’s social care who will then ‘coordinate a multi-agency professionals meeting.’
The panel also criticised the way the two agencies involved with Charlotte worked together.
It found an ‘inherent weakness in multi-agency working,’ communication between the social services and CAMHS ‘was limited to approximately five telephone calls or emails and one joint visit’ and that plans to help Charlotte were not shared between social workers and the mental health team.