Coroner's Concerns (AI summary)
Incomplete safety plans, missed professional meetings, and an unreviewed case closure by Children's Social Services left a vulnerable young person without adequate support.
View full coroner's concerns
Although a safety plan" is_prepared bY CAMHS at the time of discharge from delay hospital, there does not appear t0 be sufficient input to this document by DSS with the result that those caring for a young person at risk may have incomplete written information available to them to properly ensure the safety of the young person_ in scheduling an appropriate meeting of Professionals resulted in a missed opportunity to provide support and protection of a young person at risk and there was not therefore a prompt response to a crisis The decision to close the case (and then not to reopen the same) by DSS resulted in there being no further assessments conducted at a time when action should have been taken and could have resulted in additional support for the deceased and her family. Such a decision may not have been made if the case had been reviewed by a senior staff member who was not directly involved in the investigation.
Sent To
- Denbighshire County Council
Response Status
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On the 16th of August 2011 commenced an investigation into the death of Laura Beth Newlands (DOB 3.11.1995 DOD 12.8.2011). The investigation concluded at the end of the inquest on the 27th of November 2015 and recorded a conclusion of Suicide with the cause of death being 1(a) Trazodone Overdose
Circumstances of the Death
The Circumstances of the death are that the Deceased had been known to Denbighshire Social Services (DSS) as a result of referrals from her school and the Child and Adolescent Service (CAMHS) due to concerns relating to her self harming as a result of difficult home circumstances Although action was initially taken by DSS, her case was then closed and thereafter there was a in taking further action to provide support to her as & Professionals' Meeting was not arranged in a timely fashion and she took her own life by way of an overdose four days before the scheduled meeting:
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe your organisation has the power to take such action:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.