Media Media releases Coroner said that 17 year old Kesia Leatherbarrow’s case was littered with missed opportunities 6th January 2015 Coroner said that 17 year old Kesia Leatherbarrow’s case was littered with missed opportunities Kesia Leatherbarrow was found hanging in her friend’s garden a day after her 48 hours detention by Greater Manchester Police (GMP). She had been arrested on 30 November 2013 after she broke a window trying to enter a residential care home for people with disabilities. On arrest a small quantity of cannabis was found on her. Kesia was kept in the cells all weekend where she demonstrated extremely erratic behavior, banging her head against the wall and making threats of suicide. She was sent to court on Monday where she was bailed to return the next day due to the fact that the Youth Court did not sit on Mondays. Although she was bailed to her father’s address she left the Court alone and did not return there. The next morning Kesia was found dead in a friend’s garden. The coroner made some critical findings detailing the catalogue of errors in Kesia’s care involving the youth offending teams, social services, Child and adolescent mental health services and the Greater Manchester Police. The inquest heard evidence that there was a widespread misunderstanding about safeguarding obligations and the need for all agencies that come into contact with vulnerable children to safeguard them against the risk of harm. Failure to record, share and act on information relevant to safeguarding was also identified, this iincluded when Kesia made an explicit suicide threat in custody. The evidence in particular showed that: - There was a failure by the Lancashire Youth Offending team to process a referral order and transfer her case to Tameside when Kesia moved to Tameside. A referral order processed properly should have led to a holistic assessment of her needs as a young person and help would have been given to divert her away from the criminal justice system with the input from mental health professionals and other agencies. None of this happened with Kesia. - Tameside Children’s social services received a referral from Lancashire social services. The referral had crucial information about her history of self harm, suicidal ideation and that she had been an inpatient in and adolescent mental health unit and that she had taken an overdose in October 2013. Despite this worrying information and 3 further contacts with social services by housing support worker, the police and Kesia’s father, social services never carried out a social services assessment and did not provide any services to Kesia or her family. The only action they took was to refer her case to Tameside CAMHS who had a waiting list of 12 weeks for appointments. - Tameside CAMHS, did not act upon the serious safeguarding concerns rasied by the Tameside Children’s services and did not arrange an urgent mental health assesment. No one from CAMHS contacted Kesia and a letter acknowledging the referral was not sent out before Kesia death on 3 December 2013. - Prior to her detention in police custody on 30.11.13, Kesia came into contact with GMP on eight separate occasions in November 2013. Despite Kesia’s vulnerabilities, no referral was made to the social services and no safeguarding issues were raised. - Kesia was in custody of GMP from 9:15pm on 30.11.13 to 8:30am on 2.12.13. During her time in custody the police never completed a full risk assessment of her. She never received a mental health assessment and was only seen by Medacs nurses, neither of whom had mental health qualifications. She was never seen by a doctor and despite Kesia saying that she was on Sertraline, no efforts were made by police or nurses to find out from the family whether they could provide the medication or to prescribe the medication while she was in custody. - It took 15 hours before Kesia was provided with an appropriate adult. Neither the appropriate adult nor Kesia's solicitor were contacted in order to make representations about whether she should be kept in detention, contrary to PACE Code C. - Despite the fact that Kesia was charged with minor offences (cannabis worth £10 and criminal damage of less than £100), and that she had made admissions in relation to both offences, no consideration was given to diverting her away from the criminal justice system. - On 30.11.13 Kesia threatened to throw herself off a bridge when she left custody. No family member was informed of this threat, the police did not tell the youth offending team, and although the information was passed to the volunteer appropriate adult, no contact with social services was made directly to communicate this threat nor was a mental health assessment arranged. The nurses claimed in their evidence that the police failed to inform them that Kesia had made this suicide threat. - When Kesia left custody a prisoner escort record form was completed for her. This should include all current and historic risks but all it said was that Kesia had a history of depression and attempted suicide from November 2013. It did not include the suicide threat that Kesia had made in custody, despite all officers accepting that it should have done. This meant that the escort company GEOAMEY did not know of this risk and did not pass this information to Kesia's solicitor, the youth offending team or the court. - The police did provide information about Kesia's suicide threat to the Crime Prosecution Service (CPS). This was contained in a non-disclosable form called an MG7. It stated that Kesia had threatened to take her own life on leaving custody and that the police were concerned about her risk to herself on released. In spite of the seriousness of the concerns set out on this document, the CPS prosecutor did not pass on this information to any person concerned with Kesia's welfare or the court. The inquest heard evidence that the court would have expected to be provided with this information, particularly given that Kesia was only 17. If they had been provided with this information the court could have made it a condition of Kesia's bail that she be assessed by a mental health professional. The youth offending team stated that they would have sought mental health input if they had known about Kesia's suicide threat. - The Tameside youth offending team was at court on 2.12.13. However, the YOT representative Mr Lyons did not complete a risk assessment of Kesia. He did not ask her about whether she had any self harm or suicidal intentions. - No one raised any concerns about Kesia's mental health or safety with the court. This was in spite of her "erratic" "disturbed" and "distressed" behaviour in court and in the court cells. This included banging her head against the wall, crying and removing her clothes. A member of GEOAMEY said in his evidence that she was the most distressed that he had ever seen any detainee in 15 years of working. - Kesia was bailed to her father's address. However, no one had managed to contact Kesia's father to advise him of this and therefore when she did not show up the evening of 2.12.13 he did not take any action. Kesia had told a number of people, including her solicitor and the youth offending team worker, that she wanted to be bailed to her boyfriend's address. Police searches revealed, after she had already been bailed and left the court building, that this was an unsuitable address. One member of the youth offending team was told that Kesia's boyfriend had met her outside court. In spite of their concerns about Kesia's boyfriend, the lack of contact with Kesia's father and Kesia's own indication that she wanted to go to her boyfriend's house, no one - police, social services or youth offending team - attended the address to check that she was not there or made any efforts to escort Kesia to her father's address. Kesia’s mother Martina Brincat Baines and her step father Matthew Baines said: “We are glad that the coroner has recognised in her words that this case was littered with missed opportunities and failures both individuals and systemic. The Coroner also found that Thameside children's services dealt with Kesia was completely unsatisfactory. There were many missed opportunities for her to be seen by a mental health professional. Whilst the coroner did find that GMP failed to highlight safeguarding concerns and involve other agencies, we are disappointed that this serious failure was not found to have contributed to her death. As a family, we are utterly devastated by the loss of our beautiful daughter Kesia. Throughout the inquest, we have been horrified to discover the lack of care or action taken to protect Kesia. This was the case for the numerous agencies who each had a responsibility to safeguard our daughter. We are particularly angry that none of the family were ever informed of the threat she made, whilst in custody, to take her own life on release. We truly feel that had GMP informed us of the risk to Kesia's life, particularly given her history of mental illness, Kesia could have been saved. We can only hope that the failures highlighted in Kesia's case will result in changes to systems and attitudes, to prevent such a terrible tragedy happening to anyone else. “ Deborah Coles, co-director of INQUEST said: “This is a deeply shocking story of a vulnerable child failed by all the agencies that should have been there to protect her. Kesia did not slip through the net. Her risk factors should have been obvious to anyone who got into contact with her and yet neither an individual nor an agency made it their job to make sure that she was safe. What happened to Kesia within the last weeks of his life is a shocking catalogue of failures both in relation to diverting young women from the criminal justice system and in relation to her journey into custody, mental health and policing, use of private contractors and the treatment of children in detention. The evidence which came out of this inquest encapsulates all that we have been campaigning to change for the last 30 years. This should act as a wake up call for the agencies concerned and underlines the absolute necessity for a holistic approach when dealing with vulnerable young children.” INQUEST has been working with the family of Kesia Leatherbarrow since her death in 2013. The family is represented by INQUEST Lawyers Group members Gemma Vine from Lester Morrill solicitors and Martha Spurrier from Doughty Street Chambers.