5th September 2017

Before Senior Coroner Ms Joanne Kersley
Heywood Coroner’s Court
21 August - 1 September 2017

Charlotte Danielle Baron was a 14 year old schoolgirl, with a history of self harm and suicide attempts. On 20 February 2016, she was found hanging by her older brother at the family home. She was taken to hospital but did not regain consciousness.

The inquest jury concluded that while Charlotte was deemed as ‘high risk of self harm’ before her death, there was ‘inadequate assessment and action planning of this risk by multiple agencies’ who were involved in her care.

Following an overdose of paracetamol taken by Charlotte in September 2015, a number of agencies became and remained involved with Charlotte and her family in the months leading up to her death.  These agencies included Children Social Services, a Family Support Worker, nurses from Charlotte’s School and a Child and Adolescent Mental Health Worker.

The inquest heard evidence that the multi-agency approach involved a lack of communication, misunderstandings as to the nature and amount of care provided to Charlotte and her family and confusion as to the steps which ought to be taken by the professionals involved.

The jury said: “The circumstances in which Charlotte met her death are due to documented issues impacting on Charlotte’s emotional well-being, which resulted in a high risk of self -harm, inadequate assessment and action planning of this risk by multiple agencies and Charlotte’s unstructured home life.”

The mother of Charlotte, Ms Veronica Kilbride, said:
“I love my daughter Charlotte. She was quirky, funny, very witty, kind, considerate, loving and beautiful in every way.  I will have to live with what has happened for the rest of my life. Whilst it was difficult looking after a terminally ill mother and five children, I wish that I could have done more to help Charlotte.”

Counsel for Ms Kilbride, Ms Katy Laverty of Furnival Chambers said:
“This is a traumatic event for all involved, particularly Charlotte’s family, who continue to grieve over the loss of their beloved daughter. Hopefully lessons can be learnt from this inquest so that no other families are faced with a similar situation in the future.”

Deborah Coles, Director of INQUEST said:
“Charlotte’s death highlights the shameful state of mental health provision for children and young people in England and Wales. The failures in assessment, planning and communication regarding Charlotte’s care could and should have been avoided. Once again, INQUEST call for an urgent review of community mental health care and resources available to children and young people. This is an escalating problem with devastating consequences for the families involved and requires substantial commitment and funding from the Government to rectify.”


For further information contact Lucy McKay on [email protected] or 020 7263 1111

INQUEST have been working with the family of Charlotte Baron since her death. The family is represented by INQUEST Lawyers Group members Nicole Bridgman of Southern Solicitors and Katy Laverty of Furnival Chambers.