Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0143, written 16 Apr 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Apr 2015 |
|---|---|
| Reference | 2015-0143 |
| Deceased | Kesia Leatherbarrow |
| Coroner | Joanne Kearsley |
| Coroner area | Manchester South |
| Category | Other related deaths · Child Death (from 2015) |
| Organisation named | Pennine Care NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 4 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT |S BEING SENT TO: Chief Constable Sir Peter Fahy GMP Headquarters Central Park Northampton Road Manchester M40 5BP Steven Pleasant Chief Executive Tameside Council Council Offices Wellington Road Ashton under Lyne OL6 6DL Mr Tony Lloyd Police and Crime Commissioner - Greater Manchester Openshaw Complex Lawton Street Openshaw M11 2NS Jo Turton, Chief Executive Lancashire County Council PO Box 78 County Hall Fishergate Preston Michael Court Chief Executive Pennine Care NHS Foundation Trust 225 Old Street Ashton under Lyne OL6 7SR Chief Officer MEDACS Healthcare 7" Floor 63 St Mary Axe London EC3A 8AA Peter Lewis Chief Executive Crown Prosecution Service Rose Court 2 Southwark Bridge London SE1 9HS National Police Chiefs’ Council 1° Floor 10 Victoria Street London SW1H ONN Rt. Hon Eric Pickles MP Secretary of State for Communities and Local Government 2 Marsham Street London SW1P 4DF Rt. Hon Theresa May MP Home Secretary Home Office Direct Communications Unit 2 Marsham Street London SW1P 4DF Rt. Hon Jeremy Hunt MP Secretary of State for Health Department of Health Richmond House 79 Whitehall London SW1A 2NS CORONER | am Miss Joanne Kearsley, Area Coroner for Manchester South District. CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http:/Awww. legislation .gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION AND INQUEST On the 5" December 2013 | commenced an investigation into the death of Kesia Lena Mary Leatherbarrow aged 17 years. The investigation concluded at the end of the Inquest on the 6" February 2015. The Conclusion recorded was a narrative conclusion indicating that, on the 3 December 2013 at (NN the deceased died as a result of tying a ligature around her neck. There is not sufficient evidence to indicate that she was intending to end her life. The deceased had moved to the Manchester area on the 26" October 2013 since when she had interactions with a number of agencies. There had been missed opportunities for agencies to obtain and collate information, to carry out adequate assessments of the information they held and to consider appropriate levels of support. Despite these failings there is not the evidence to say on the balance of probabilities that any of these matters caused or contributed to her death. CIRCUMSTANCES OF THE DEATH | do not propose to detail the significant evidence that was heard in this case save to say that the brief circumstances were as follows: The deceased had always resided with her family in the Lancashire area. There had been increasing concern about her behaviour including her drug use, her abusive and aggressive outbursts, self-harming and her mental health. She had spent a month in July 2013 in the Platform facility in Preston, Lancashire. This is a mental health facility for young people. Upon her discharge matters deteriorated and on the 25th October Kesia was arrested by Lancashire Police. Her behaviour whilst in custody was concerning but she was not deemed to require sectioning under the Mental Health Act. Following her release from custody on the 26" October she threatened to jump from a bridge. The same day she went to live with her Father in the Tameside area of Manchester. Kesia had had little contact with her Father and he was not aware of all the recent issues and concerns surrounding Kesia. From this point onwards Kesia had little contact with her mother and step- father who understandably had been severely impacted by the difficulties they had faced with Kesia. Due to concerns about her behaviour whilst she was in police custody in Lancashire, Lancashire Constabulary raised a safeguarding report to the Multi-Agency Safeguarding Hub (MASH) which led to a referral to Lancashire Children’s Services. This referral indicated that Kesia was a high risk and likely to self-harm. Given that Kesia was now residing in the Tameside Area the referral was then forwarded by Lancashire Children’s Services to Tameside Children’s Services. Upon receiving the referral only part of the information provided by Lancashire was then cut and pasted onto Tameside’s own Referral Form which was inputted onto the computer system. There was therefore incomplete information on their own form although the Lancashire form was also scanned onto the Tameside Computer system. When the case was reviewed not all of the information was considered as only the incomplete Tameside form was ever read. A decision was taken not to open a file and conduct a social work assessment for Kesia but to send a referral to the Child Adolescent and Mental Health Service (CAMHS). Upon receipt of this referral Pennine NHS Foundation Trust assessed the information provided by Tameside and sent the referral to the administrator of the service for an appointment to be sent to Kesia. No appointment had been sent to Kesia at the time of her death. As a result of her arrest in Lancashire, Kesia was before the Magistrates Court in Preston on the 5" November 2013. She received a referral order. Lancashire Youth Offending Team attended court and noted Kesia’s new address in Tameside. However the case, which was then considered by at least 4 people in the Lancashire Youth Offending Team, was not transferred over to the Tameside Youth Offending Team at all prior to Kesia’s death. On four occasions there was a failure to notice the new address for Kesia which was clearly marked on the documentation on the file. This meant that the referral order assessment and panel process was not commenced and concluded within the national guidelines prior to her death. There was also inappropriate thought given to breaching Kesia for non- compliance of her referral order. From the 26'" October 2013 (whilst in the Manchester area) Kesia, on at least 8 occasions prior to her arrest on the 30" November, had some interaction with officers from Greater Manchester Police. On one occasion she was reported as missing from home by her Father; she was located the following day residing with her boyfriend at the Armadale Road address. On two occasions Kesia made calls to the police with allegations of domestic violence against her by her boyfriend. On another occasion she made a report of an assault against her by the ex- partner of her boyfriend. On the 25"" November Kesia attended at her Mother’s home in Lancashire where she was aggressive, threatened to push her grandmother down the stairs and had hold of a knife whilst threatening to self-harm. Officers from Lancashire Constabulary attended, Kesia was calm at the time of their arrival and she was taken back to her Father's house by her Grandmother. Her Father was not provided with information as to the exact nature of what had occurred. Lancashire Constabulary made a further referral to their MASH which assessed Kesia as a Medium Risk. Following her move to the Manchester area the Inquest heard evidence which indicated that from shortly after the 26"" October Kesia was not in fact residing at her Father’s. She was in reality spending a lot of time residing with her boyfriend and also staying in other accommodation. On the 30" November Kesia was arrested in Manchester by Greater Manchester Police for criminal damage and possession of cannabis. Shortly after her arrest and before her arrival at the police station, Kesia’s presentation changed and she was extremely abusive and aggressive. She remained in police custody, for reasons set out below, until the Monday morning when she was placed before the Court. Her behaviour whilst in custody was of concern to custody staff and on two occasions police requested the attendance of medical professionals from MEDACS. Whilst in custody, at the time of the first medical assessment, Kesia made a threat to jump off a bridge if she was released from custody. This was documented on the Risk Assessment Form on the custody record. A full risk assessment was not completed on her arrival into custody nor at any stage during her time in the police station. Following her initial assessment by MEDACS there was a reasonable assessment made that Kesia was intoxicated and a decision taken to allow her time to sleep and potentially sober up. The Inquest heard evidence that the first nurse was not able to complete her assessment of Kesia at this stage. A second assessment by MEDACS was conducted sometime later. The Inquest heard evidence about this assessment and also viewed the CCTV footage. The Inquest found that this assessment was incomplete and fell well short of being a meaningful assessment. In addition the Inquest heard evidence as to whether MEDACS should be able to access records held about an individual if they had been assessed by their staff in a different police force area. When assessed in Manchester by MEDACS access to her Lancashire MEDACS records would not have been possible as her name had been entered as unknown and not updated. During her interview and subsequent time in custody Kesia’s behaviour remained concerning. A decision was taken not to bail Kesia but to keep her in custody in part due to the concerns officers had about her safety. The Inquest heard evidence as to the legislation surrounding 17 year olds in custody and additionally the availability of PACE beds for children in custody. Whilst in custody Kesia had access to an appropriate adult. The request for an appropriate adult was made by Greater Manchester police to Tameside Social Services. A form was then sent to the volunteer who attended the police station. In Manchester the volunteer Appropriate Adult Scheme is run by the Police and Crime Commissioner (PCC). The form completed by the appropriate adult should then be faxed back to Social Services. This did not happen. Information about the threat Kesia had made to jump off a bridge was passed to the Crown Prosecution Service (CPS) by way of the MG7 but it was not noted on the Prisoner Escort Record. At Court Kesia was seen by her solicitor, Tameside Youth Offending Team and GEO Amey staff before her appearance in Court. At no stage did they become aware of the threat Kesia had made whilst in police custody as this was known only to the CPS. No remand application was made therefore the CPS did not place the information as to her threat before the Court. Whilst being held at the Magistrates Court Kesia’s behaviour caused concern. Bail checks on appropriate addresses were not carried out. Kesia was released with a bail condition of residence at her Father's address. She left court and went to her boyfriend’s address where she stayed the night. She was found later the next morning in the garden of the property having tied a ligature around her neck. Coroner Concerns During the course of the Inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows:- GOVERNMENT Legislation and the provision of Local Authority Accommodation 1. The Inquest heard evidence that recent changes to legislation means that whilst in custody 17 year olds are now treated as children for the purposes of the Police and Criminal Evidence Act (PACE). However the failure to make legislative changes to the supporting legislation means that for 17 year olds there is an anomaly in the system particularly around the provision of accommodation for a 17 year old who is refused bail. For these purposes a 17 year old is still classed as an adult and not a child and therefore there is no requirement for local authorities to provide accommodation. This would require primary legislation. There remains no legal requirement for local authorities to provide accommodation for 17 year olds who will then have to remain in police custody if bail is refused. The result is that 17 year old children risk being kept in custody for longer than necessary if there is nowhere suitable for them to be bailed to. 2. In addition the Inquest also heard evidence as to the reality of the situation in practice and the availability of such accommodation for those children to whom the law currently does apply i.e. 16 years and younger. The Inquest heard that across Greater Manchester it is estimated that, until recently, in only 10% of cases where the police requested such a service from a local authority a bed was available. Attempts are being made to address this issue but at present the figure remains at approximately 20% and the Inquest heard evidence that this was, “not good enough’. Again the facts heard at this Inquest seem to suggest that children younger than 17 are at risk of being held in custody longer than necessary due to a lack of appropriate facilities. The court heard evidence that the police are in the undesirable position of having to decide whether to detain someone (potentially unlawfully) or release them when they feel it may be unsafe to do so. 3. It was clear throughout the Inquest that the legislation relating to 17 year olds presented challenges to those professionals who had contact with Kesia. For the purposes of safeguarding and the Children’s Act she remained a child, being someone under the age of 18. Equally, however, she was old enough to consent to be in a sexual relationship. The Court was left with little doubt that the differing legislative provisions for 17 year olds pose unique challenges for professionals in dealing with people of this age. ACPO NATIONAL POLICE ISSUE Exit Risk Assessments 1. The Court heard that since Kesia’s death Greater Manchester Police have implemented a system to try and ensure that this situation does not happen again. It was therefore decided to hold a joint medical and police exit risk assessment when someone who has displayed self- harm ideation or behaviour leaves custody. Initially this was introduced for people aged 17 and under but as of January 2015 it was extended to all people leaving custody. Whilst this has been a significant commitment from Greater Manchester Police and has required the funding for an additional Doctor the Court heard evidence that so far this risk assessment has been conducted on over 144 people leaving custody. This is clearly capturing a large number of people who are displaying signs of similar behaviour or thoughts as Kesia did whilst in custody and the Court heard that a joint medical and police risk assessment on their exit from custody is essential in trying to ensure appropriate support when they leave the police station. LANCASHIRE YOUTH OFFENDING TEAM AND TAMESIDE YOUTH OFFENDING TEAM 1. The Court heard evidence as to the poor understanding and communication between the Youth Offending teams of Lancashire and Tameside following Kesia’s re-location to the Manchester Area. There was a failure by Lancashire to note her move which led to a delay in her case being transferred, but in addition there was a failure in the communications with Tameside for each team to understand what was being requested and to have oversight of the situation. This led to a lack of involvement with Kesia and a proposal to breach her. It also meant that no effective work was being carried out with her and a missed opportunity to recognise her developing situation in terms of her lack of residence and drug use. GREATER MANCHETSER POLICE Safequarding Responsibilities 1. The Inquest heard a great deal of evidence from officers as to their understanding and actions. No intelligence was placed on Kesia’s nominal profile despite a number of concerning contacts with her by officers. It is a core function of the police to submit such intelligence. . Greater Manchester Police has no stand-alone safeguarding policy for matters which are not criminal. There is no clear guidance to officers regarding what to do to raise safeguarding issues. There is no process for the recording of safeguarding concerns. There is confusion and a lack of understanding as to which agencies officers should refer to and where this should be recorded. The fact that there was no record of Greater Manchester Police’s involvement with Kesia, despite her having been reported missing from home, information about drugs, self-harm and being in a relationship with a much older individual did not flag-up one safeguarding referral to another agency was concerning. Force Wide Incident Notices (FWINS) ‘Ls There were a number of reported incidents relating to Kesia and her involvement with Greater Manchester police which necessitated the opening of a FWIN. The Court heard evidence as to the failure to pass on complete information to the officers who then subsequently attended on Kesia including on one occasion the fact that it had been communicated that she had a knife. The court heard evidence that the failure to pass on important information could impact on the safety of the officers and others and also lead to missed opportunities for safeguarding. Closing Codes for Domestic Violence Incidents if Evidence was heard that when a FWIN is closed a code is attached to it. For domestic violence incidents the closing code relates to people over the age of 16 as being adults. This means that the case is not then automatically passed through to the Child Protection Team within Greater Manchester Police for a review even if one of the people involved is still a child - i.e. is 17 years of age. Whilst the case would still be considered by the Public Protection Investigation Unit however the availability for the child protection unit to have all the information relating to children may be beneficial. Checks carried out by Public Protection Investigation Unit its Evidence was given to the Court that when a Domestic Abuse, Stalking and Harassment form (DASH) is submitted to the PPI unit, where the risk level is standard then no checks on the Police National Computer or the Police National Database are carried out. The rationale for this was not clear although DC Evans indicated this may be due to the volume of work. Clearly the PNC can hold vital information about a potential offender. 10 Custody Handovers 1. The Court heard evidence that the handovers which ensure that custody officers taking charge for detainees and their welfare have to conduct such handovers in their own time. The system at present relies on officers and staff attending work early and sometimes staying late after a 12 hour shift to provide a handover. Whilst it is clear there would need to be some overlap in the times people are on duty, the Court heard evidence as to the quality of the handovers which is clearly impacted by the fact that this crucial part of the information sharing process relies entirely on the free-time of officers and staff. The Court was advised that the provision of custody within GMP is currently under review but at present the position remains as it was in 2013. Completion of the Prisoner Escort Record 1. The Prisoner Escort Record form was completed over 12 hours prior to Kesia leaving police custody. It was not checked or amended prior to her release and it failed to contain crucial information indicating that whilst in custody Kesia had made a threat to jump from a bridge. This should have been included. GREATER MANCHESTER POLICE AND _PENNINE CARE NHS FOUNDATION TRUST Tameside Diversion Project 1. The Court heard evidence regarding a project in Tameside similar to one in Newcastle the aim of which was apparently to divert young people from the Criminal Justice System. However the Court heard that the Tameside Youth Diversion Project is not working as intended. The plan being that once someone is arrested there should be consideration to diverting the young person away from the Criminal Justice System if there is evidence of emotional disturbance / self-harm, etc. The court heard evidence that in Tameside this signposting is only taking place to the mental health services once the young person has been processed through the Criminal Justice System and is not in fact acting as a diversion pathway. There was no evidence from those working in custody that any consideration was given to this scheme for Kesia and there appeared to be little knowledge of the scheme. On the face of the evidence the current system appeared to duplicate the work carried out by the 16-19 Mental Health Service. GREATER MANCHESTER POLICE / POLICE AND CRIME COMMISSIONER AND LOCAL AUTHORITIES 11 Appropriate Adult Scheme: These concerns relate solely to the Appropriate Adult Scheme. During the course of the Inquest the Court received a copy of the Protocol in place between the Police and Crime Commissioners Office, the Local Authorities and the Police. Evidence was heard from the Social Worker who received the call from GMP requesting an Appropriate Adult for Kesia and the Appropriate Adult who attended. yf The evidence of the Social Worker was that until the commencement of the Inquest she was not aware and had not had sight of the Protocol document. It was her understanding that in all cases except for murder/rape and terrorism offences that an Appropriate Adult from the volunteer scheme would attend. It was not her understanding of the system in place that she should be assessing the information given to her by the police to consider whether it was more suitable for the attendance of a Social Worker. She indicated that if she had been aware of this she would have made further enquiries as to how Kesia was presenting in custody in order to make that assessment. She also indicated that when she was contacted by Greater Manchester Police no concerns at all were raised as to how Kesia had been in custody ( at this stage she had been in custody for over 12 hours). She was not advised that Kesia had been assessed as intoxicated on arrival, nor that she had been seen by MEDACS, nor that she had threatened to jump off a bridge on her release. She indicated that if she had been aware of these matters she would have asked her colleague social worker who was also on call and who was an approved Mental Health Social Worker to attend as the Appropriate Adult. The Court heard evidence that following her attendance the appropriate adult completed the relevant form which would normally be faxed back to Social Services by Greater Manchester Police Officers. It was her understanding that this was the responsibility of Greater Manchester Police and that she also thought that on receiving the form Social Services may want to, “ do something further possibly have proper metal health assessment on Kesia”. Evidence from Tameside Social Services indicated that they did not receive the completed form in relation to Kesia and that it was not unusual not to receive the completed forms in any cases. Whilst the Court was informed that the PCC have facilitated the availability of equipment to Greater Manchester Police so that the form can be scanned back to Social Services, there was nothing in the protocol document which placed the responsibility for the return of this form_on the Custody Staff. Nor was any evidence presented that 12 Custody Staff had been made aware that this was their specific responsibility. Having heard the evidence It seems that the Custody Staff can be very busy and the passing of this responsibility to them is onerous. Allowing the Appropriate Adults to use the relevant equipment themselves before they leave to ensure that they fulfil their responsibilities is one thing, but the complete abrogation of responsibility from the Appropriate Adult to Custody Staff who have no role save to telephone social services requesting an Appropriate Adult is entirely different. Indeed given the independence of the Appropriate Adult and their role it may also be a conflict. Similarly the Court heard evidence as to the signing of the Appropriate Adult Form by the Custody Sergeant. It was confirmed in evidence by Sergeant Simpson that his understanding is he signs the form so as to confirm what time the Appropriate Adult finishes dealing with the detained person. It is not his role to oversee the quality of the work. and advice given by the Appropriate Adult. Again there did not appear to be anything in the protocol to suggest that this was a responsibility which had been accepted by Greater Manchester Police. The quality of the information given by the appropriate adult on the completed form was insufficient in light of all the information which had been made available to her about Kesia and the behaviour she had witnessed. Important information such as the threat made by Kesia was not placed onto the form which in correct circumstances should have been passed onto social services for their consideration — particularly given that Kesia was a child and there were obvious safeguarding concerns. . For children in custody where there are significant concerns as to their behaviour and risk to themselves and no family members have been identified as suitable Appropriate Adults ( or who will not attend) consideration should be given as to whether the Appropriate Adult should in all cases be a social worker. MEDACS dy The Court heard and saw CCTV evidence of the second medical assessment which was conducted on Kesia. It was the Court's view that this fell far short of what was expected in order to reach any conclusions as to the fitness and wellbeing of Kesia. It was clear that a medical assessment could not be completed and in these circumstances this should be fully explained to the police and the record endorsed accordingly rather than simply endorsing that someone is fit to be detained/interviewed or transferred. 13 2. The Court also heard evidence that the same medical assessment is carried out for every detained person in custody regardless of whether that is a 17 year old child with mental health difficulties or a 69 year old man with a heart condition. There is no difference in the mental health assessments for children as opposed to adults. Consideration should be given as to any different requirements for the assessment of children, who by nature of the fact that they are in a police station are in a particularly difficult and vulnerable situation. 3. Similarly the Court heard that no safeguarding referral was made about Kesia despite information about her self-harming, drug and alcohol use. MEDACS and GREATER MANCHESTER POLICE 1. The Court heard evidence as to the reasons why Greater Manchester Police requested the attendance of MEDACS. It was apparent to the Court that the expectations of the police as to the precise medical assessment being carried out and the conclusions of the assessment may not always be the same as the expectations and understanding of MEDACS. So for example the police may consider they are requesting MEDACS for a mental health assessment and the assessment in reality may simply assess whether the individual is fit to be detained. There needs to be greater understanding between the police and MEDACS as to what the assessment has consisted of and what it has concluded and how. 2. In addition, prior to a medical assessment taking place, there should be a full record made as to what information MEDACS staff have had access to. The Court heard evidence in this case that on some occasions a copy of the custody record may be physically available for MEDACS staff but there was no clarity as to whether this included previous risk assessments, whether this was a complete record and there was no recorded evidence to indicate what information had been passed to MEDACS by the police and who had provided the information. CROWN PROSECUTION SERVICE 1. Whilst recognising that the CPS do not have the same safeguarding responsibilities they had clear evidence as to the threat that Kesia had made and this was not put before the Court nor passed on to any other agencies. Nor was any additional information sought from GMP. There was a lack of understanding between GMP and the CPS as to how such important information should be shared between ‘agencies. PENNINE CARE NHS FOUNDATIONS TRUST / TAMESIDE YOUTH OFFENDING TEAM and MEDACS 1. The Court heard evidence about two matters involving Mental Health 14 Services and other agencies. IMI gave evidence that in his view there would be interaction between their service and Tameside Youth Offending Team with regards to Kesia. This would either be done once the case had been passed to Amy Valentine or if Tameside YOT contacted their service. This did not occur as the file had not been processed at the time of Kesia’s death but also because of the confusion between the Youth Offending Teams involved with Kesia which meant she was never picked up by Tameside. The plan that Kesia should be monitored for any interim changes in her risk did not therefore occur. GREATER MANCHESTER LOCAL AUTHORITIES AND GREATER MANCHESTER POLICE Multi- Agency Safeguarding Hubs mh The Court heard evidence as to the effective working in Lancashire County Council and Lancashire Constabulary of the Multi-Agency Safeguarding Hub (MASH). It was clear from the evidence that the interactions Lancashire Constabulary Officers had with Kesia led to a simple, effective means of passing on safeguarding information to the MASH. This was not the system in Manchester and the Court heard evidence that the development of MASHs across Manchester is still ongoing. The Court heard evidence that in Manchester different hubs work differently with different agendas — some relate to domestic violence only and not all of them deal with safeguarding of children. The Court was advised that the plan is that by the end of the year across Manchester there will be fully operational safeguarding hubs but that each different local authority wants to go about it in a different way. This will mean that there is a lack of consistency in approach across the different local authorities in Manchester as to what will be dealt with. Worryingly some will not deal with the safeguarding of children and such an approach may lead to a lack of consensus and understanding of their roles. In addition such an individual approach will need careful understanding by other agencies as to what can be referred and what cannot — potentially exacerbating an already difficult and confusing situation. ALL AGENCIES 1. Having heard the evidence the Court felt that there was a degree of confusion and misunderstanding between all the agencies as to their roles, what they are able and not able to do and also where to access important and effective information. By way of brief examples, when Kesia was in custody MEDACS contacted the Crisis Team to see if Kesia was known to them, Kesia had never been involved with the Crisis Team. There was no contact made with the Mental Health Services who did have information that she was waiting for an 15 appointment or with the Youth Offending Team. Tameside Youth Offending Team did not have access to Tameside Children’s Social Care records so did not realise that Kesia had been referred to them. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 11" June 2015. |, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely, namely to the family of Kesia. | am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. Date: 16" April 2015 Miss Joanne Kearsley H M Area Coroner Manchester South
4 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Je Crd te Peter Lewis CB Chief Executive Miss J Kearsley Area Coroner — Manchester South Coroner's Court 1 Mount Tabor Street STOCKPORT 7 Your Ref: JSP/KN/02606-2013 15 June 2015 Dear Miss Kearsley, Re: Kesia Lena Mary LEATHERBARROW (Deceased) | refer to your letter of 16 April enclosing your Regulation 28 Report. | have noted carefully the background to this very regrettable incident and the concerns you have expressed, particularly those concerning the Crown Prosecution Service (CPS). | have now obtained a report from vr Acting Chief Crown Prosecutor for CPS North West. | am aware that he ensured the CPS in Greater Manchester co-operated with the Inquest procedure throughout and was represented by counsel at the hearing earlier this year. As you rightly highlight in your letter, a number of agencies have taken steps to change their practices and this includes the CPS. | accept that it is critical that vital information about the welfare of individuals held in custody pending their first appearance before the court, is shared as efficiently as possible. This is particularly important in proceedings involving young people such as Kesia. The Chief Crown Prosecutor for Greater Manchester is in dialogue with the relevant Assistant Chief Constable for GMP, participating in his “Gold meetings” associated with this case, and looking at the wider issues and lessons which can be learned from the tragic outcome of Kesia’s case. The good working practice identified in Lancashire is being considered as part of this exercise. The CPS Operations Directorate has also been considering the national implications and as a result ensured we have modified CPS training so advocates conducting youth court cases are reminded that a youth can always be remanded for their “own welfare”. INVESTORS IN PEOPLE Private Office, Crown Prosecution Service, Rose Court, 2 Southwark Bridge Road, Southwark, London SE1 9HS Telephone: 020 3357 0891 Email: privateoffice@cps.gsi.gov.uk Web: www.cps.gov.uk As you mention in your Report, recent changes in legislation, particularly the newly enacted Legal Aid and Sentencing of Offenders Act, should ameliorate the Position of those attaining the age of 17 so that they are treated for custody purposes as all other youths. Please do not hesitate to contact me again if you feel | can assist further. Yours sincerely, Veer bound PETER LEWIS CHIEF EXECUTIVE
aoe Rt Hon Alistair Burt MP Minister of State for Community and Social Care Department of H ealth Richmond House 79 Whitehall London SWI1A 2NS POC3000940554 Tel: 020 7210 4850 Mr J. Pollard Senior Coroner Coroner’s Court 1 Mount Tabor Street Stockport 18 JUN 2015 SK1 3AG Dew My Pollard , Thank you for your letter of 16 April 2015 following the inquest into the death of Kesia Leatherbarrow. I was very sorry to hear of Kesia’s death and wish to extend my sincere condolences to her family. You found that there were missed opportunities for the many agencies involved in Kesia’s care to obtain and collate information, to carry out adequate assessments of the information they held and to consider appropriate levels of support. Although no NHS bodies appear to have been involved directly with Kesia there are important learning points for both this department and the NHS. Many of the issues you raise in your report concern the actions and lack of coordination of the local services. We have therefore shared your report with NHS England. NHS England confirms that there was no nationally specified Liaison and Diversion (L&D) provision in Greater Manchester at the time of Kesia’s death. These services identify, assess and refer people with mental health, learning disability, substance misuse and social vulnerabilities at first contact with the police and criminal justice system. The NHS England Health & Justice North West Team is currently working with providers within the Greater Manchester area to develop L&D in line with the national specification. Extending the L&D national service specification to all of England will be dependent on approval by H.M. Treasury. On the provision of mental health services generally, children, young people and those who care for them should be able to obtain high quality mental health care when they need it. The Children and Young People’s Mental Health Taskforce, jointly chaired by the Department of Health and NHS England, has considered the specific issues facing highly vulnerable children and young people who find it particularly difficult to use appropriate services. In March, the Government published a report of the Taskforce’s work, Future in Mind. This sets out a national ambition to transform the design of services for children and young people with mental health needs. This includes linking services so pathways are easier to navigate for all, particularly the most vulnerable. NHS England is reshaping the way these mental health services are commissioned and delivered over the next 5 years. Its current planning guidance, Forward View into Action, emphasises the importance of joint work across agencies. It has also published a model service specification for child and adolescent mental health services to assist local commissioners in commissioning services involving multiagency care. NHS England will prioritise further investment (announced in the Autumn Statement and recent budget) in those areas that have published Local Transformation Plans aligned with the overarching principles described in the Future in Mind report. From April 2016, NHS England will take on commissioning responsibility for healthcare for people in police custody. A partnership board of NHS England and the 40 English police forces will take this work forward. Further background information can be found at: http://www.england.nhs.uk/commissioning/health-just/ I hope that you find this reply helpful and that the actions being taken give some re- assurance to you and Kesia’s family of the importance of improving provision. I am grateful to you for bringing the circumstances of her death to my attention fa Sen tanh Dp OSL —_— ALISTAIR BURT
Sec wre ke Home Secretary 2 Marsham Street . i-4 ff London SW1P ome Office Leen SAO Miss Joanne Kearsley Area Coroner, Manchester South Coroner’s Court 1 Mounth Tabor Street Stockport SK1 3AG 10 June 2015 Dear Joanne, Regulation 28 report: The inquest of Kesia Lena Mary Leatherbarrow Thank you for your letter of 16 April and for sharing your findings in relation to the tragic death of Kesia Leatherbarrow. | take this case and the treatment of children and. vulnerable people by the police extremely seriously and am committed to taking action. Your report, sent under Paragraph 7 of Schedule 5 to the Coroners and Justice Act 2009 and Regulation 28 of the Coroners (Investigations) Regulations 2013, covered a range of matters and identified a number of concerns, some of which are the responsibility of other agencies. You will understand, therefore, that in this letter | will respond to the matters addressed directly to the Government for which the Home Office has responsibility. 17 year olds under Police and Criminal Evidence Act 1984 Your report sets out that PACE legislation should be amended so that 17 year olds are always treated as children. Following a review of the provisions concerning the treatment of 17 year olds under the Police and Criminal Evidence Act 1984, the Government has committed to changing the law to ensure that 17 year olds are treated in the same way as 10 to 16 year olds as soon as a legislative opportunity arises. In November 2014 we were able to work closely with the Ministry of Justice to use the Third Reading of the Criminal Justice and Courts Bill to make a partial change to the current provisions in PACE, specifically in respect to Part IV of PACE (including Section 38(6)), relating to police detention. The Criminal Justice and Courts Act subsequently received Royal Assent on 12 February and PACE has been changed to require 17 year olds, for the purposes of detention after charge, to be treated as 10 to 16 year olds in police custody and therefore be transferred to local authority accommodation. Planning is underway to amend the remaining provisions of PACE which treat 17 year olds as adults, which | intend to include in the forthcoming Policing Reform and Criminal Justice Bill, announced in the Queen’s Speech on 27 May 2015. Transfer of children under Section 38(6) Your report sets out that the provision of local authority accommodation is insufficient. As part of the work to extend Section 38(6) of PACE my officials became aware of issues concerning the operation of this provision. This is deeply concerning and in January the Secretary of State for Education and | wrote to local authorities in England reminding them of their absolute duty of care under Section 21(2)(b) of the Children Act 1989 to provide accommodation for children denied bail under Section 38(6) of PACE. In March, the National Policing Lead for Custody wrote to all forces reminding them of their responsibilities to ensure that as few children as possibie are spending time detained in police custody. | have commissioned the establishment of a multi-agency working group to better understand the issues and develop solutions. No child should be spending time in custody unnecessarily. Every death is a tragedy, particularly in the very sad circumstances surrounding Kesia Leatherbarrow. This Government is committed to ensuring that children and vulnerable people more generally are treated appropriately, that police officers are more effective in spotting signs of distress, and that children are treated with dignity and respect. a The Rt. Hon Theresa May MP
ahaa) Pennine Care NHS} NHS Foundation Trust Trust Headquarters 225 Old Street Ashton-under-Lyne Lancashire OL6 7SR Telephone: 0161 716 3000 15™ June 2015 Our Ref: MMc/KH STRICTLY PRIVATE & CONFIDENTIAL Departient: Trust Headquarters Extension: Miss J Kearsley Fax: 0161 716 3037 Area Coroner HM Coroner Manchester South The Coroner's Court Mount Tabor Mottram Street Stockport, SK1 3PA By e-mail: joanne.kearsley@stockport.gov.uk a Dear Miss Kearsley Re: KESIA LEATHERBARROW 7 Thank you for your letter of 16" April enclosing your Regulation 28 report. At page 13 you have dealt with issues relating to Pennine Care NHS Foundation Trust and have stated .......... “the Court hea t about two matters involving Mental Health services and other agencies. gave evidence that in his view there would be interaction between their service and Tameside Youth Offending Team with regards to Kesia. This would either be done once the case had been passed to Amy Valentine or if Tameside YOT contacted their service. This did not occur as the file has not been processed at the time of Kesia’s death but also because of the confusion between the Youth Offending Team involved with Kesia which meant that she was never picked up by Tameside. The plan that Kesia should be monitored for any interim changes in her risk did not therefore occur’. In January 2014 the Trust completed their investigation into their involvement with Kesia and identified a number of problems which reflect your own findings. These included:- 1. Kesia had prior involvement from Mental Health Services in Chorley and recent involvement with the police in Tameside. Adequate and timely sharing of information was not undertaken. 2 t ABO, Zs fe Cfe4/s RS < 2057» Visit us on www.penninecare.nhs.uk sae 2. There had been no transition of care from Chorley Mental Health and Youth Offending Services or multi-agency support and therefore there was limited information available regarding Kesia’s needs. 3. There was no contact with CAMHS services by the police following Kesia having been in police custody the preceding weekend despite an established diversion pathway, and a specific Youth Justice Mental Health Practitioner being in post. 4. Although Kesia’s referral was screened in a timely manner, contingency advice about accessing more urgent or emergency mental health assessment within Tameside had not been provided to Kesia and her family. 5. The response to the referrer and written letter to Kesia and her carers regarding the confirmation of her appointment date, details and information regarding the service had not been despatched at the time of her death. 6. Awritten summary of all letters from Chorley Mental Health Services and a summary from her in-patient admission were not available and may have been relevant in supporting decision making. An action plan was implemented following the Trust’s review which included:- 1. The development of a single point of access. CAMHS and RAID workers now hit SIT together to ensure that patients can be speedily and effectively referred to the appropriate service. A tracking system has been implemented to monitor and ensure administration time scales are being met. This recommendation has been incorporated into the Tameside CAMHS 16 ~ 18 referral protocol which deals with routine referrals by the Tameside Access Team, inappropriate routine referrals and referrals by the RAID team. Tracking pro formas are now completed. The pro forma and referral are passed to the administrator who notes the outcome of the MDT discussion (during which the client has been discussed) in the referral book. If felt appropriate, the administrator identifies a suitable time and date following discussion with the team. There follows a standard letter sent to confirm receipt of the referral and advise of the time, date, location and identity of the assessors to the young person. The letter provides information with regards to an interim safety plan. The letter advises the referrer and the young person’s GP that the referral has been received, screened and accepted for assessment. A file is then made up by the administrator which contains a copy of the referral and accompanying paperwork. This is placed in the drawer of the 16 — 18 office which contains 12 slings each designated to a particular month. The current month’s sling is audited on a weekly basis during the whole team meeting and remedial action is taken in the event of any delay in the referral process. When referrals are accepted a further letter confirming the appointment is sent within 21 days of the appointment. 2. It is now standard practise that upon receipt of referrals where there has been prior involvement with young people from other mental health services the CAMHS mental health team ensure written clinical summaries, including risk assessments and care plans are requested in addition to telephone contact made to gather background information. 3. The health diversion pathway has been re-published and re-promoted to Tameside Police and the Youth Offending Team to increase use of the pathway. The Youth Justice Mental Health Practitioner is now jointly supervised by Pennine Care. 4. The multi-agency panel for vulnerable offenders which meets every two weeks now also has capacity to deal with children and young people. Individuals are discussed during these local meetings and ways in which they can be diverted from the criminal justice system considered. The emphasis now is to ensure children do not remain in police custody or other penal institutions. The Trust accepts and shares the concerns that have been raised by you and has taken appropriate steps to minimise the risk of similar problems arising in the future. Those working at the Trust with young people believe there has been a total cultural shift within GMP with an emphasis on safeguarding children and primary consideration as to how children and young people can be diverted from the criminal justice system. Yours sincerel ) Michael McCourt Chief Executive
See every Prevention of Future Deaths report matching Pennine Care NHS Foundation Trust, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.