Social services missed chances to help teenager who killed herself, coroner says

Social care agencies “missed opportunities” to help an aspiring teenage model who went on to take her own life.

Coroner Katy Skerrett said there was a lack of communication by mental health and social care professionals in the treatment provided to 17-year-old Anielka Jennings.

The teenager was found dead at her home in Tredworth, Gloucester, on February 5 last year by her father, months after she had been removed from a social services child protection plan.

Gloucestershire Coroner’s Court heard that Anielka had spent much of her teenage years battling mental and physical health problems, had started using drugs and alcohol and had begun an exploitative relationship with a 39-year-old man.

Anielka had been a healthy child until she suffered brain damage after a sudden stroke at the age of 12 and later underwent a heart transplant at Great Ormond Street Hospital in London.

As her mental health declined she was seen by a range of different professionals, including psychiatrists, education psychologists, neuropsychologists and pastoral carers.

But no single individual was responsible for overseeing the many agencies contributing to her care.

The inquest heard Anielka’s mother Aleksandra had requested two emergency mental health appointments for her daughter in the six months before her death but was not seen until January 16 last year.

Fighting back tears, Mrs Jennings told the inquest: “I made clear this was an emergency situation – when someone is drowning, you don’t wait.

“Anielka was in a situation that I felt she didn’t have professional help when she was in the most critical situation. She was all lonely and that is what hurts me most.”

The teenager told a health worker of her problems but she was not assessed at risk of suicide and her case was not considered to be “highly urgent”. Her file was passed to a doctor but she died before an appointment was made.

Anielka, who had been due to start a filmmaking course at Gloucestershire College, had left a suicide note for her parents. A post mortem examination found she died as a result of hanging.

The hearing heard from an independent expert who criticised the decision by social services to downgrade Anielka’s child protection plan – describing it as a “huge step down”.

Consultant psychiatrist Judith Barnsley said: “The risks were increasing. I still think people had a duty to think how to protect her and keep her safe.

“She was working with some agencies but despite that the risks were increasing.”

Dr Barnsley added: “I think it has to be acknowledged that child mental health services are under huge pressure and there are delays of waiting times that no-one wants but it is a national problem.”

The 2gether NHS Foundation Trust, which provides mental health services in Gloucestershire, acknowledged shortcomings.

Consultant psychiatrist Paul Winterbottom, who at the time of the Anielka’s death was medical director, said: “I think in retrospect we certainly could have made improvements.

“I think perhaps we lacked a complete and co-ordinated perspective at the limited opportunities we had to assess Anielka.”

Ms Skerrett, senior coroner for Gloucestershire, recorded a combined conclusion of suicide and a narrative.

“She developed complicated neuro-psychological problems arising from the brain injury caused by the stroke,” she said.

“Anielka’s home life was difficult and she was often reluctant to engage with professionals.

“She engaged in risk taking behaviours, which included on occasion self-harming, alcohol, illicit drug use and becoming involved in inappropriate relationships.

“In December 2014 Anielka was taken off a child protection plan which had been in place since 2011.

“Her care was being transitioned from child and young person’s services to adult services. Multiple agencies were involved in Anielka’s care and her complex needs were identified.

“However no lead professional was identified to coordinate her care. On more than one occasion the agencies did not communicate with each other.

“This led to missed opportunities to provide a structured care plan for Anielka.”

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