Social care agencies missed opportunities to help a 17-year-old girl who took her own life months after being removed from a child protection plan, a coroner has ruled.
Katy Skerrett, the senior coroner for Gloucestershire, said there had been a lack of communication between mental health and social care professionals in the treatment provided to Anielka Jennings.
Anielka had spent much of her teenage years battling mental and physical health problems, had started using drugs and alcohol, and had begun an exploitative relationship with a 39-year-old man.
The court heard that the girl, from Gloucester, suffered brain damage after a sudden stroke at the age of 12 and later underwent a heart transplant.
As her mental health declined, she was seen by a range of professionals, including psychiatrists, educational psychologists, neuropsychologists and pastoral carers. No single individual, however, was responsible for overseeing the many agencies contributing to her care.
Anielka told a health worker of her problems, but she was not assessed at risk of suicide and her case was not considered to be “highly urgent”. Her file was passed to a doctor, but she died before an appointment was made.
The teenager, who had been due to start a film-making course at Gloucestershire College, left a suicide note for her parents. A postmortem examination found she died as a result of hanging.
The hearing heard from an independent expert, the consultant psychiatrist Judith Barnsley, who criticised the decision to downgrade Anielka’s child protection plan, describing it as a “huge step down”.
The 2gether NHS Foundation Trust, which provides mental health services in Gloucestershire, acknowledged shortcomings.
The consultant psychiatrist Paul Winterbottom, who at the time of Anielka’s death was 2gether’s medical director, said: “I think in retrospect we certainly could have made improvements. I think perhaps we lacked a complete and coordinated perspective at the limited opportunities we had to assess Anielka.”
Skerrett recorded a combined conclusion of suicide and a narrative.
She said: “In December 2014 Anielka was taken off a child protection plan which had been in place since 2011. Her care was being transitioned from child and young person’s services to adult services. Multiple agencies were involved in Anielka’s care and her complex needs were identified.
“However no lead professional was identified to coordinate her care. On more than one occasion the agencies did not communicate with each other. This led to missed opportunities to provide a structured care plan for Anielka.”
• In the UK, the Samaritans can be contacted on 116 123. In the US, the National Suicide Prevention Hotline is 1-800-273-8255. In Australia, the crisis support service Lifeline is on 13 11 14. Hotlines in other countries can be found here
