The mother of a 16 year old boy who died whilst in the care of a children’s home is calling for lessons to be learned, as the Inquest into his death found significant failings in the safeguarding procedures and care provided to him whilst placed at Cherry Tree Children’s Home.
The Inquest into the death of 16 year old Daniel Sewell-French (Danny) concluded yesterday (6th June 2017). Danny died in his bedroom on 2nd October 2016 whilst placed at the children’s home, which is run by Blackburn with Darwen Borough Council.
The Inquest heard that on the evening of 1st October 2016 at 7pm Danny had returned to the home very intoxicated. Whilst back at the home Danny consumed more alcohol, morphine and buprenorphine. The last time he was checked by staff was in the early hours of Sunday 2nd October 2016. He was found dead later that morning at around 11:30 am.
Danny died from Morphine Toxicity after taking morphine sulphate with alcohol and the painkiller buprenorphine.
The Senior Coroner in the Inquest into the death of Danny, a vulnerable young man in care, concluded that clear and significant failures in safeguarding procedures contributed to his death.
The Senior Coroner found that;
- No adequate steps were taken to ensure that Danny was not in possession of drugs and alcohol when he returned to the home on the evening of 1st October 2016;
- Only a ‘cursory search’ of Danny’s room was undertaken which was a ‘clear and significant failure’ to identify that he was in possession of drugs and alcohol, not only for safeguarding Danny but also for the safeguarding of all of the other children in the home;
- Insufficient observations were in place for Danny, meaning that the opportunity was lost to administer naloxone (a drug used to treat potential drug overdose) earlier.
The Senior Coroner also criticised the home for not acknowledging or adhering to a risk assessment that had been put in place in the management of Danny’s care. This risk assessment had been reviewed by management at the home just two days prior to Danny’s death.
A Serious Case Review into Danny’s death is currently ongoing.
Danny’s mother, Barbara said;
“The inquest found that Danny was badly let down by significant failings in his care. Danny was vulnerable and we believed he would be kept safe and looked after. I am now looking forward to the Serious Case Review making changes to the safeguarding systems in place at the home, so that lessons can be learned from Danny’s tragic death and no more families are put in this position.’
Kelly Darlington, Solicitor for Danny’s mother said;
“This is an extremely tragic case involving a vulnerable child. We are pleased that the Coroner identified that there were serious issues in Danny’s care that contributed to his death. It is hoped that lessons can be learned from this tragedy to ensure that other children are safeguarded in the future.”
More information on this inquest can be found here