On the 12/h February 2015, commenced an investigation into the death of Anielka Agnes Grace Marie Jennings. The investigation concluded at the end of the inquest on the 15" June 2016. The conclusion of the inquest was a short form suicide with narrative conclusion. The medical cause of death was 1A Vasovagal Inhibition as a result of 1B Hanging:

This 17 year old young lady "Anielka" was diagnosed with cardiomyopathy in March 2010, aged 12 years and she suffered a stroke. She underwent a heart transplant in April 2010_ Post procedure she recovered well from a cardiac perspective. However, she developed complicated neuro-psychological problems arising from the brain injury caused by the stroke Anielka's home life was difficult; and she was often reluctant to engage with professionals. She engaged in risk taking behaviours, which included on occasion self-harming, alcohol; illicit use , and becoming involved in inappropriate relationships. In December 2014, Anielka was taken off child protection plan which had been in place since 2011. Her care was transitioned from child and young person's services to adult services Multiple agencies were involved with 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 January 2015, Anielka drew on her bedroom walls a number of images which indicated suicidal intent Local mental health services were not made aware of this_ On the 4"h February 2015, she attended her final appointment at the children's transplant clinic_ She travelled to Great Ormond Street with her father. Her journey was delayed by fatality occurring on the railway line. She was also very upset after reading a report that referred to her ongoing need for support and services. The following day on the 5"h February 2015, she left her father in Gloucester centre at approximately 10OOhrs She made her way to her training college She then departed for home. Her father returned home at about 1500 hours and found Anielka hanging by the neck from the bannister. dressing gown cord had been used as the ligature. Her father cut her down and dialled emergency services_ Paramedics arrived shortly thereafter and pronounced Anielka deceased at 1510 hours Police are satisfied there are no suspicious circumstances suicide note was found at scene. Gloucestershire Coroner'$ Court; Corinium Avenue; Barnwood, Gloucester, GLA JDJ Tel 01452 305661 Fax 01452 412618 drug being City

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