Prevention of Future Deaths Report Raised Following Inquest into the Death of A

The inquest into the death of A concluded in April 2024. The inquest was held over 6 days before Assistant Coroner Miss Thistlethwaite for Leicester City and South Leicester. Following the inquest, the coroner prepared a Prevention of Future Deaths Report to United Children’s Services (“UCS”). UCS have now provided their response.

A was 16 years old when they died in August 2021. They identified as non-binary. A had complex needs and had been known to social services and mental health services throughout their life. At the time of their death, they were a resident at a therapeutic care home ran by UCS.

A had a long history of self-harming and experienced both auditory and visual hallucinations. The inquest heard how there was a decline in A’s mental health in January 2021.

On 5-6 August 2021, A’s behaviour was such that staff at the home implemented an “ad hoc waking night”, which was a form of 1:1 support with a care home worker sitting outside their open bedroom door throughout the night. A had consumed alcohol this evening and there were concerns about the effects of the alcohol whilst A was on anti-psychotic medication. During the waking night, A made superficial cuts to their neck in the bathroom and a blade was later removed from A.

The next night, there was no ad hoc waking night cover implemented. On the morning of 7 August 2021, A was not checked at 7:00am as stipulated in their care plan. Staff did not complete their checks on A until approximately 9:00am, at which time they found A, having ligatured.

It was accepted at the inquest that UCS’s investigation into A’s death was “not fit for purpose” because it failed to identify all of the learning arising from A’s death.

Submissions were provided to the coroner on why a Prevention of Future Deaths Report (Regulation 28 Report) was required.

The coroner issued a Prevention of Future Deaths Report to UCS to highlight the following concerns:

• A was subject to a Ligature Risk Assessment after they ligatured in December 2020. At the time the risk was deemed to be ‘medium’. In April 2021, the risk was re-assessed and deemed to be ‘low’. At some point after this review, a decision was made to remove A’s personal Ligature Risk Assessment. There was no documentation relating to the date that decision was made or the reasons why. The coroner considered this lack of documentation “a grave concern”.

• The coroner raised concerns about lack of documentation and poor communication. As well as no documentation around the removal of the Ligature Risk Assessment, there was no documentation to explain the deviation from A’s care plan on the morning that they died, and there was little or no communication of A’s historic Child Sexual Exploitation risk between the care home A was in and her previous home, both ran by UCS.

• Evidence was heard that the decision to implement ad hoc waking night cover was based upon the gut instinct of the staff on duty and there was no policy to specifically deal with ad hoc waking nights, meaning the decision making would not be consistent and the level of care provided to children in the care of UCS was heavily dependent on which staff member was on duty at the time. Further, there is no step-down process. In A’s case, they went from having a staff member outside their door throughout the night of 5-6 August to having a period of 11 hours entirely unsupervised throughout the following night of 6-7 August, during which time A ended their life.

• It was in A’s support plan that they were to be checked on every morning at 7:00am. A was not checked upon until 9:00am on the day that they died, in breach of their support plan. There was no documentation or justification around this decision.

• The inquest heard that new staff members have 6 months to complete their training, meaning it was possible to have staff members working with children with complex needs and vulnerabilities who have not completed their training and so do not have a full understanding of the spectrum of their needs.

• Evidence was given by UCS that an investigation took place and was not formally documented but was discussed at a UCS board meeting around 6-7 months after the death. At the time of the inquest, 2 years and 8 months after the death, the changes discussed at the board meeting had “not yet” been made.

• The coroner also raised concerns about policies and processes and that whilst UCS planned to make changes to these, at the time of preparing the report those changes had not been finalised.

In July 2024, UCS provided their response to the coroner, stating that:

• There is a Home Ligature Risk Assessment which applies to all young people and A was subject to an individual Self Harm Risk Assessment. UCS have now streamlined risk assessments into one document and require a date to be recorded for any reviews.

• They do not agree that decision making around ad hoc waking nights was heavily dependent on which staff member is on duty at the relevant time. They say staff make these decisions in discussion with each other and with the approval of the Registered Manager. UCS accept that the procedure for ad hoc waking nights was not detailed within the Sleeping and Night Supervisions Policy and that it should have been, which has now been updated. UCS also agreed it would be beneficial to introduce a “step down” procedure.

• A’s care plan should have been updated to reflect their sleeping pattern.

• All staff complete induction training within the first month of joining, including policies on Child Sexual Exploitation. Additional training is completed across a six-month probation period and a staff member who has not yet passed probation is rostered to be on shift with a staff member who has passed probation.

• They initiated an internal investigation a few weeks after A died and regret that they did not document the investigation and conclusions. They now require an independent third-party to conduct the investigation.

A’s mother was represented by Alice Wood of Farleys Solicitors and Lucy McCann of 1 Crown Office Row.

If you’re looking for legal representation for the inquest into the death of a loved one, please get in touch with Farleys’ inquest specialists today on 0845 287 0939, by email, or through the online chat below.