Joseph Southam was a 15-year-old school boy from Wirksworth who died following a heroin overdose in July 2014. Despite being in contact with a number of agencies, the inquest into his death heard evidence that professionals failed to appreciate that he was a child at risk and thus failed to implement any safeguarding measures to protect him.

The inquest heard evidence that this young boy had a history of low mood and anxiety, died as a consequence of risk-taking behaviour in which he would experiment with known drugs and other chemicals he had researched and acquired from the internet. He had been buying drugs from an unregulated part of the internet known as the “dark web”. Despite taking a form of LSD into his school, police were not alerted. Sadly, six months later he died when he took heroin he had paid for online.

A report commissioned by Child and Adolescent Mental Health Services was heavily criticised by Dr Hunter, Senior Coroner for Derby and Derbyshire in which its author Joanne Kennedy, a Consultant Child and Adolescent Psychiatrist, said agencies were “working in isolation” in their treatment of him.

Dr Hunter asked this witness how she could conclude that his death could not have been predicted when he was being managed in a disjointed and dysfunctional system. The Coroner went on to say; “I am sick to death of hearing that deaths cannot be prevented or predicted but in this case there have been serious failings in the clinical acumen or those involved were wilfully blind to the facts. This was crying out for the involvement of social services.” The inquest revealed a number of failures in the way in which Joe was managed by a number of agencies including the police, social services, mental health services and hospital. All agencies failed to fully appreciate and recognise his mental health issues and risk of harm.

The Coroner concluded that “None of the agencies directed their minds to Joseph’s family unit which was under considerable pressure. Having considered all of the evidence and the magnitude of the failings I find it as fact that had there been a developed and focused care plan in place then, on the balance of probability, Joseph would not have died when he did.”

The Inquest heard that since his tragic death a number of measures have been implemented by Derbyshire Healthcare NHS Foundation Trust to improve the training of staff in mental health services, and importantly to educate staff on the importance of information sharing across professionals and partner agencies.

Tragic cases like these are being reported almost daily and we see the same failings in the care of young people struggling to cope with mental health problems time and time again. The child and adolescent mental health system is in place to protect those children who are vulnerable and yet it continues to take devastating cases like this to expose the severity and magnitude of the shortcomings that exist and bring about the changes that are so desperately needed.

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