Coroner has ‘concerns about care company’

PREVENTION OF FUTURE DEATH REPORT AFTER TEEN TOOK LIFE

A CORONER has expressed concerns about a company which runs a care home for children in Leicester.

An inquest was held last week into the death of 16-year-old Ash Bannister, who used the pronouns they/their.

It concluded they took their own life at The Laurels, run by United Children’s Services, in Groby Road, Leicester.

Coroner Isobel Thistlethwaite has issued a Prevention of Future Death Report to United Children’s Services.

She said: “During the course of the investigation, my inquiries revealed matters giving rise to concern.

“In my opinion there is a risk that future deaths could occur unless action is taken.”

Ms Thistlethwaite, assistant coroner for Leicester City and South Leicestershire, highlighted three main areas of concern: that Ash was removed from a risk assessment which identified them as being at risk of taking their own life; that Ash was not watched for several hours when they should have been regularly observed; and the company’s “inadequate” investigations process.

The inquest heard Ash, who had been self-harming from the age of nine, had been made the subject of a ligature risk assessment.

But at some point shortly before they died, in August 2021, that risk assessment was removed, with no documentation to say exactly when or why.

On the night of their death, Ash should have been checked on at 7am, but no check was carried out, in breach of the home’s policy.

Ash was unsupervised for 11 hours, despite having been on constant watch – waking night cover – the day before.

The coroner said in the report she had “heard conflicting evidence” as to whether an investigation was undertaken by United Children’s Services.

The inquest heard evidence there was no investigation, while one manager said there was, but the results were not documented.

Ms Thistlethwaite said: “I heard evidence to confirm United Children’s Services do have an investigations policy, albeit that document was not disclosed to the court.”

She said a United Children’s Services board meeting took place in spring 2022 during which required changes to policies and processes were discussed.

She said: “I asked why changes had not been made and was told United Children’s Services wanted to get the inquest process out of the way before making any changes. “I have grave concerns about the fact United Children’s Services have been running homes in the knowledge that they have an inadequate investigation process in place for over two years.

“I have concerns about policies and processes in place at United Children’s Services, including the investigations policy, the policies governing risk assessments, in particular the ligature risk assessment, and the ad hoc waking nights process.

“I heard evidence about United Children’s Service’s plan to make what appear on the face of it to be broad and wide-reaching changes.

“However, at the time of writing this report those changes have not been discussed, finalised, implemented or embedded.

“The children in the care of the United Children’s Services will, in my opinion, remain at risk until such time as appropriate and effective action is taken.”

The company is required to respond to the coroner within 56 days with details of what actions will be taken.

Children... will remain at risk until such time as appropriate and effective action is taken

Coroner