The inquest into the death of Charlotte Baron concluded on 01 September 2017. The inquest was heard by HM Senior Coroner for Manchester (North) Area, Joanne Kearsley.  Charlotte Danielle Baron was a 14 year old schoolgirl, with a history of self harm and suicide attempts. On 20 February 2016, she was found hanging by her older brother at the family home. She was taken to hospital but did not regain consciousness.

The inquest heard evidence that while Charlotte was deemed as ‘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’.

Following an overdose of paracetamol taken by Charlotte in September 2015, an action plan was put in place.  This action plan triggered agency involvement such as Rochdale Council Childrens Services, The Child and Adolescent Mental Health Services (CAMHS) and school support services at Charlotte’s high school.

The inquest heard evidence that the multi-agency approach involved a lack of communication, misunderstandings as to the nature and amount of care provided to Charlotte and her family and confusion as to the steps which ought to be taken by the professionals involved. The Coroner described the record keeping in this case as ‘woeful’.

These agencies were brought together at varying stages. The agencies were required to provide informal updates to other agencies through day to day communications and record keeping and formal updates as part of the Child In Need meetings.

The Child In Need meetings were a chance for all agencies to sit together and review the action plan in place for Charlotte, to provide updates as to what their agency had been working on and how Charlottes risk was progressing. The Child and Adolescent Mental Health worker never attended any of the Child In Need meetings relating to Charlotte which meant other agencies were in the dark concerning Charlotte’s mental health issues and her risk.

During the Inquest numerous agencies gave evidence and told the court that they were unaware of Charlotte’s history of self harm, her high risk level and the problems Charlotte was having at home. Agencies were also unaware of how often Charlotte was meeting with mental health services.

Agencies stressed at the inquest that the ‘child’s voice’ is important during social service involvement. Charlotte had made it clear to agencies from their initial engagement that she was unhappy living at home. Charlotte had concerns about her relationship with her mum and so Charlotte spent the majority of her time at friends, ‘sofa surfing’, or at her dad’s house. Charlotte had contact with her dad and would go nightly after school and spend time at his home. The Coroner offered some criticism that Charlotte’s father was not invited to any of the Child In Need meetings and was unaware of the difficulties with his daughter as agencies did not involve him.

After hearing all the evidence the Jury returned with a conclusion of misadventure. The Jury noted “documented issues impacting on Charlotte’s emotional wellbeing, which resulted in a risk of Self Harm, inadequate assessment and action planning of this risk by multiple agencies and Charlotte’s unstructured home life” as being relevant to the circumstances surrounding Charlotte’s death.

This case is a clear example of an extremely vulnerable child under the radar of social services who was not adequately assessed or supported. There were missed opportunities by staff working with Charlotte to recognise and appreciate her level of risk and ensure that she was prioritised and received the help and support she needed.

The family were represented by INQUEST Lawyers Group members Kelly Darlington and Jillian Newton of Farleys solicitors and Barrister Andrew Bridgeman of St Johns Buildings.

Here at Farleys, our experienced Inquest team understand the distress and anguish that a death of a family member can cause. We can provide advice, assistance, and representation to ensure that you are fully supported throughout such a difficult time. It is important that your concerns surrounding the death of your family member are appropriately addressed. If you require assistance with the inquest process but are concerned about how much it will cost to obtain such representation, you may be eligible for public funding. For legal advice regarding the death of a loved one please don’t hesitate to contact our experienced Inquest department on 0845 050 1958 or alternatively you can email us.

Read more about the case here