On 28/h 2017 | commenced an investigation into the death of Rebecca ROMERO , aged 15 years_ The investigation concluded at the end of the inquest on 13" December 2017. The medical cause of death was given as: la Hanging The conclusion was: Accidental death contributed to by neglect

Rebecca Romero died on 19"h July 2017 at her home address. She had been found in the bathroom with a ligature around her neck and she died from the injuries sustained: Rebecca had been discharged from a psychiatric unit on 14 July 2017 and was under the care of the community team at the time of her death. She had not been seen since her discharge. Rebecca had a long history of self harm and mental health problems; she was described as appearing very vulnerable with very few factors of resilience. In June 2016 she began using ligaturing as a means qf self harm. It was agreed by a number of witnesses that that elevated Becky's risk On 10lh June 2017 she was admitted to Pebble Lodge Adolescent Unit in Dorset as there were no beds for her in the local area of Bristol at the Unit called Rlverside. On 6th July she was released for a period of leave; what in fact transpired was she never returned to Pebble Lodge after this period of leave On 14"h July there was a discharge meeting and a community care package was into place. was told that the original plan was to arrange to transfer Becky to Riverside but as there was no place available attempts were made to discharge her to Riverside as a placement patient: Unfortunately there were no_ placements available elther therefore a community care package was put into place. One witness described the community care package as "it just didn"t feel very comfortable.' Furthermore the evidence at the inquest from NHS England was at the time of Beckys Jay July put day and day discharge that a patient placement was available at Riverside An independent witness also gave evidence at the inquest and said he was concerned about the length of time that Becky was without a medical review and that post discharge was at a very high risk time. He stated that the amount of contact from the 6"h July to the time of her death was not acceptable and that the plan to see Becky once a week following her discharge was not sufficient: A number of other points were raised at the inquest as follows: In relation to the transfer from Pebble Lodge to Riverside it appears that a Form was submitted to Riverside on 5"h June but that the referral was closed on 6"h There appeared to be confusion by some as to whether this was being followed up. The community care plan that was in place from 14"h had no dates for tasks to be completed or for meetings to take place, by way of example at the time of her: death a medical review appointment was still not in the Different people described Beckys risks in different ways, terminology such as loW, medium or high were used to describe her risk but others used significant or low and even on the date of discharge her risks were described in different ways Part of the care plan was for there to be communication by text with Becky up until the time of her death there was only one text sent which was effectively confirming an appointment for after her death and simply stating "how are was told that there is no current training or guidance given to staff_ This case highlighted some of the difficulties in transferring children to an in-patient unit'out of the area and then arranging to transfer them back to the area

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action: