‘More could and should have been done’ to help tragic teenager

Damn­ing re­port slams agen­cies

Rochdale Observer - - FRONT PAGE - Da­mon.wilkin­son@men-news.co.uk @Da­monWilkin­son6

ADAMNING 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 self-harm­ing.

Prior to her death she had tried to take her own life to two sep­a­rate oc­ca­sions.

Now a Se­ri­ous Case Re­view (SCR) pub­lished this week 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.


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 self-harm 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 Rochdale work­ers from 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’.


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 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 record­keep­ing in CAMHS were also found to be fallen ‘much short of agency stan­dards’.


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 mul­ti­a­gency 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.

●●Char­lotte Baron had been self-harm­ing and made two at­tempts to take her own life be­fore her death

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