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Investigation and inquest
On 02 October 2019 I commenced an investigation into the death of Nathan Tesla George SCANTLEBURY aged 16. The investigation concluded at the end of the inquest on 15 July 2024. The conclusion of the inquest was that:
Nathan Tesla George Scantlebury died as a consequence of asphyxia following a ████████. The ████████ event was a deliberate act but it cannot be established on the evidence that he intended the outcome to be fatal.
Nate’s death was contributed to by:-
i. A failure to take appropriate steps to ensure Nate’s safety when the ████████ was first observed and whilst it was still loose; and
ii. Neglect
Nate’s death was possibly contributed to by:-
i. The lack of availability generally of suitable placements for children with complex mental health needs.
ii. Failures by the Local Authority and the Clinical Commissioning Group to adequately assess the suitability of the placement to meet Nate’s needs;
iii. A lack of understanding by the local authority and the clinical commissioning group of the way in which the model of care used in the placement worked in practice and whether this would meet Nate’s needs.
iv. Failings by the clinical commissioning group and the local authority to ensure that a s117 after-care plan in place to ensure that all professionals involved in Nate’s care were aware of their respective role and responsibilities
Circumstances of the death
Nathan Scantlebury was just 16 years old at the time of his death. He had a complex mental health needs and was a looked after child, having been so since December 2013.
Nate had a significant history of self-harm and spent several periods detained under the Mental Health Act. Nate had previously been placed at a placement in Wales, specialising in providing care to Young People with high risk self-harming behaviours. Following a serious incident in August 2018, Nate was detained under the Mental Health Act with the placement considering they could no longer keep him safe.
Following a period of detention, the only placement available for Nate was in a mainly adult service, with a least restrictive approach adopting a therapeutic risk-taking and recovery-based approach. The service provided care for those aged between 16 and 25.
During the course of Nate’s placement, a number of concerns were raised in respect of the suitability of the service for Nate, with a number of self-harming incidents taking place which required hospital treatment.
On the 25th September 2019, Nate tied a ████████ around his neck, initially the ████████ was loose and Nate was left whilst advice was obtained. Nate was later found laid on his bed, blue in colour and unresponsive with the ████████ tight around his neck. The ████████ was removed and Nate’s physical observations taken with further advice being sought and observations taken prior to an ambulance being called. Nate was taken to hospital and pronounced deceased a short time later.
Coroner’s concerns
The lack of availability of suitable placements for high risk children with complex mental health needs which is both a local and a national issue which has been ongoing for a number of years.
Information checked against the published report and official responses