Henry Grierson

PFD Report All Responded Ref: 2024-0598
Date of Report 4 November 2024
Coroner Angela Brocklehurst
Response Deadline est. 30 December 2024
All 1 response received · Deadline: 30 Dec 2024
Sent To
Response Status
Responses 1 of 1
56-Day Deadline 30 Dec 2024
All responses received
About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Coroner’s Concerns
On the 13th November 2023 Henry Joseph Grierson with the consent of his Parents discontinued his referral and treatment from the organisation CAMHS, and on the 9th April 2024, Mr Grierson gave notice if his intention to discharge himself from the support organisation Recovery Steps. No evidence has been presented to this Inquest as to the knowledge of these matters by the safeguarding team at Huddersfield New College. No information concerning the current mental health issues of Mr Grierson had been provided to the College within a mitigation statement provided by him. The evidence before the Court is that the latest communication concerning Mr Grierson's mental health provided by CAMHS was dated October 2023. It is a matter of concern that communication between the college and CAMHS and Recovery Steps was not seemingly maintained to enable an awareness by the College of the current mental health of Mr Grierson in April 2024 and the decisions taken by himself and his family, to remove such external support.
Responses
Huddersfield New College
23 Dec 2024
Huddersfield New College has already reviewed and amended its policies and processes for contacting external agencies and requesting updates, especially for students with Welfare Plans, to improve information sharing. They have also met with the Department for Education and NHS Trust to advocate for better multi-agency communication. AI summary
View full response
Dear Madam, The College will always do anything we can to support our students, and we welcome the Coroner’s findings. We agree with the Coroner’s conclusion that steps need to be taken to enhance the communication from organisations such as CAMHS to schools and colleges, but consider this to be a conversation that needs to be had at a much higher level. Given that the College does not have the power to make and implement changes on behalf of other organisations, we have met with representatives of the Department for Education to explain the issues and to bring their attention to the challenges regarding multi-agency communication. The provision of clearer guidance about what triggers communication from such organisations would provide valuable clarity for the whole sector. Notwithstanding our view that the discussion around multi-agency co-operation is not completely within our purview, representatives from the College have discussed the issue with their counterparts at the NHS South West Yorkshire Partnership Foundation Trust who have responsibility for CAMHS. In terms of steps that may be taken locally to improve the communication of information we can only act on matters within our control. We understand that the Trust have agreed in principle to write to you to set out the steps they will take as the provider of CAMHS services to address the concern you have raised. In terms of matters that are within our control, the College has reviewed and amended relevant policies and processes for contacting external agencies, particularly where a Welfare Plan has been created or when permanent exclusion is being implemented as a last resort. Included in this review of processes is College staff requesting and expecting updates from the external agencies involved in the safeguarding of a student, as identified and specified in their Welfare Plan. The College’s safeguarding team will remind external agencies of the responsibilities that they have to share safeguarding information, as detailed in ‘Keeping Children Safe in Education’ and ‘Working Together to Safeguard Children 2023’. Since the Coroner’s issuing of the Regulation 28 Report, the College’s safeguarding team have found that information-sharing from external agencies to the College has already improved, specifically external agencies informing us when they have discharged a student under their care.
Report Sections
Investigation and Inquest
On 30 April 2024 I commenced an investigation into the death of Henry Joseph GRIERSON aged 17. The investigation concluded at the end of the inquest on 31 October 2024. The conclusion of the inquest was that: See Narrative Conclusion.
Circumstances of the Death
Henry was as last seen by his parents on the 20th April 24, at 22:15 hours at his home address when he went to bed. He was described as being in good spirits. After his parents had gone to bed, it is believed Henry has left the address in his fathers mother vehicle and is stopped by the Police and the vehicle was seized by Police at 02:15 hours. Following this it is believed Henry has returned home and written in a diary his intention to commit suicide to his family members and has time stamped these in the diary. The time when he started was 0613 hours and finished it at 06:41 hours. It is then believed Henry has taken a length of blue rope from his father's shed and has left the area and walked to a wooded area behind the William Henry school in Rastrick. Henry has then . Henry was found by the a member of the public who was out walking their dog. The emergency services have been contacted and on arrival the Police, have started CPR until the Paramedics arrived who reported life extinct at 10:11 hours.
Related Inquiry Recommendations

Public inquiry recommendations addressing similar themes

Conduct inter-agency review of child abuse investigation procedures to issue guidance
Waterhouse Inquiry
Inter-agency benefit data sharing Missed Child Safeguarding Referrals
Share HTA reports with reliant organisations
Fuller Inquiry
Inter-agency benefit data sharing
Pre-1996 Transfusion Testing
Infected Blood Inquiry
Incomplete GP Patient Data Transfer
New Patient Registration Screening
Infected Blood Inquiry
Incomplete GP Patient Data Transfer
School-to-college records on radicalisation vulnerability
Manchester Arena Inquiry
Missed Child Safeguarding Referrals
School records on radicalisation vulnerability
Manchester Arena Inquiry
Missed Child Safeguarding Referrals
Record images of students with weapons
Manchester Arena Inquiry
Missed Child Safeguarding Referrals
Create diocesan safeguarding officers
IICSA
Missed Child Safeguarding Referrals
Church in Wales provincial safeguarding officers
IICSA
Missed Child Safeguarding Referrals
Church in Wales record-keeping policies
IICSA
Missed Child Safeguarding Referrals

Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.