On 11th June 2014 | commenced an investigation into the death of Sian Leigh ARMSTRONG, Aged 17 . The investigation conciuded at the end of the inquest on 14" January 2015. The conclusion of the inquest was as follows: Medical Cause of Death 1a) Hanging Conclusion Sian Armstrong had a history of depression, she was under the care of the mental health service and on the balance of probability took her own life.

Sian had a history of depression; In March 2014 she made an attempt on her life bv way ofan overdose. Following this she had been seen by the Mental Health Team; Sian was assesgee as needing to receive CBT but from the time of the assessment in March 2014 until her death in June 2014 she had not received CBT CoRONERS CONCERNS During the course of the inquest the evidence revealed matters giving rise to conern: In 'opinion there is a risk that future deaths will occur unless action is taken In the my circumstances it is my statutory duty to report to you: The MATTERS OF CONCERN are as follows_ There was a delay in Sian receiving CBT which she was assessed as requiring: At the inquest indicated that would ask North Bristol NHS Trust for reassurance that steps will be taken to ensure that this therapy is available to children who are assessed as needing it in a timely manner

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

Medical Cause of Death 1a) Hanging Conclusion Sian Armstrong had a history of depression, she was under the care of the mental health service and on the balance of probability took her own life.