Teenager who took her own life failed by children’s mental health services, finds review

Cumbria’s child and adolescent mental health services have been condemned in a serious case review of the 2013 suicide of 15-year-old Helena Farrell.

The Kendal teenager, named as ‘Child J’ in the report, took her own life on 4 January last year – one day after an initial assessment by Barrow in Furness CAMHS concluded she was at high risk of future self-harm and medium risk of suicide.

It followed two referrals to the service that were delayed – and in the first instance, not allocated at all – while crucial signs were missed by other professionals who, for the most part, were inexperienced in managing suicidal behaviour in young people.

The review’s findings are also critical of school staff and GPs who were “dazzled” by high-achieving Miss Farrell’s intelligence and outgoing, positive nature. They drew “naive and over-simplistic conclusions”, it reports, into her state of mind in the wake of a paracetamol overdose and disclosures by friends that she was planning to take her life.

But it singles out an alarming “pattern of agencies ‘investing in’ CAMHS as if it is a functioning service and the solution to young people’s difficulties when they know it’s not, [creating] a false reassurance that children will receive the help that they need in a timely fashion”.

A referral to CAMHS made on 10 December 2012 received no response, while a re-referral on 20 December – made in the wake of suicide letters being found – was delayed for eight days and only allocated when one of Miss Farrell’s parents contacted CAMHS directly on 2 January 2013.

Despite apparent confidence at the time from other professionals involved in the case, the review found:

• Professionals did not have high expectations of the response from CAMHS to the referrals they made
• They commented on extreme delays with referrals and a lack of clarity over who is being seen by whom
• It was not uncommon for there to be no notification of the end of CAMHS involvement or the outcome of the intervention

The report also states: “Staff from CAMHS described the service as being in a state of chaos and that Child J’s case was not unusual. They reported long standing deep seated difficulties and referred to low levels of morale, high staff turnover and sickness absence. Staff commented on the frequent changes of senior managers and the consequent lack of leadership and direction.”

The review found that identical concerns highlighted by a serious case review in 2011 had gone unresolved, and that “the response to any young person with Child J’s difficulties would remain inconsistent”.

Richard Simpson, assistant director (children’s services) for Barnardo’s Cumbria, who chaired Cumbria’s local safeguarding children board at the time of the report’s writing, said: “Child J’s death was tragic and I would like to express our sincere condolences to her family and friends. The report outlines how services did not function as well as they should have to help prevent her from harm [and] asks serious questions for which there are few straightforward answers.”

The serious case review also found a general lack of confidence from local agencies that referrals to Cumbria’s children’s services would be accepted, deterring professionals from making contact. An Ofsted inspection report from May 2013 found the authority’s overall safeguarding arrangements, quality and practice, and leadership and governance to be ‘inadequate’.

John Macilwraith, acting corporate director for children’s services, said: “Cumbria County Council is the lead agency in terms of safeguarding and protecting children and young people from harm, and while in this case we did not have any direct involvement, the failure of others to ask for our assistance due to an apparent lack of faith in our services is troubling.

He added: “Since Ofsted’s judgement early last year we have been working incredibly hard to improve the quality of the services we offer. The most recent assessment by the independent Chair of the body overseeing our improvement plan says that we are making good progress, but we must maintain and build upon this momentum. We owe it to all children and families to be there for them when they need us.”

Dr. Sara Munro, director of quality and nursing for Cumbria Partnership NHS Foundation Trust, said: “The serious case review found that the circumstances leading up to her death were very complex and this led to her level of risk being very difficult to fully assess.

“There was an unacceptable delay in her being seen by the CAMHS service and we have made significant improvements to that service. This includes the appointment of a new clinical director, four new consultant psychiatrists, an introduction of the out of hours services, a new senior team for the service. These changes have been independently assessed to be working well..”

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