‘High-risk teenager was let down by agencies’ – inquest
ATROUBLED teenager deemed at ‘high risk of selfharm’ was let down by authorities before she took her own life, an inquest has ruled.
Charlotte Baron, 14, was found hanged in her bedroom in February 2016.
She died in hospital after her body was found by her brother, Tylor, at their home in Falinge.
An inquest jury concluded that while Charlotte was deemed at a ‘high risk of self harm’ before her death, there was ‘inadequate assessment and action planning of this risk by multiple agencies’ who were involved in her care.
A two-week inquest into her death, which concluded on Friday, heard how she had been self-harming from the age of 11 after battling ‘body issues’ and had tried to kill herself on two previous occasions.
She kept a diary in which she penned a series of drawings depicting self harm and wrote about her unhappiness.
One heartbreaking entry told of an incident where she wished she died after being admitted to hospital following an alcohol binge.
The inquest also heard how the ‘bright and popular’ St Cuthbert’s High School pupil had a difficult relationship with her mum, Veronica Kilbride, who struggled with a drink problem.
Her home life was described as ‘dismal’, with the family home in Heights Lane often without food, electricity or heating.
And at the time of Charlotte’s death her grandma, Maureen Henry, to whom she was close and had expressed a desire to live with, had been diagnosed with terminal cancer.
Social workers from Rochdale council were assigned to both Charlotte, who had four siblings, and the family as a whole following her first suicide attempt in September 2015.
Charlotte was also being seen by a mental health worker from Pennine Care NHS Trust.
But the jury criticised their efforts saying Charlotte had been ‘inadequately assessed’ by ‘multiple agencies’.
Delivering its conclusion of death by misadventure, the jury said: “The circumstances in which Charlotte met her death are due to documented issues impacting on Charlotte’s emotional well-being, which resulted in a high risk of self harm, inadequate assessment and action planning of this risk by multiple agencies and Charlotte’s unstructured home life.”
Following the conclusion senior coroner Joanne Kearsley said she would be writing what is known as a ‘preventing future deaths’ report, which will be published in seven days. It is expected to be critical of the way the authorities handled Charlotte’s case.
Earlier Ms Kearsley had indicated she would be reporting some of the professionals involved in the case to the relevant regulatory bodies and had described record keeping by all the authorities involved with Charlotte as ‘woeful’.
A serious case review (SCR) into the circumstances surrounding Charlotte’s death is also expected to be published this week.
In a statement the Rochdale Borough Safeguarding Children Board (RBSCB), which is responsible for carrying out the SCR, said: “The RBSCB completed the serious case review in March 2017 and will publish the full anonymised report following the coroner’s findings in this case.
“All agencies involved in the case have submitted action plans and the board has monitored the implementation of these plans.”
Sara Barnes, Healthy Young Minds Directorate Manager at Pennine Care NHS Foundation Trust, said: “On behalf the Trust, I would like to offer my sincere condolences to Charlotte’s family.]
“We respect the outcome of the inquest and will work with partner agencies to implement the recommendations set out by the coroner.
“Pennine Care routinely carries out internal investigations in the event of a tragic incident, as we are committed to ensuring the Trust learns and improves practice.
“It is our absolute priority to provide services that are safe and effective for patients, their families and carers, as well as the general public.”