Laura Beth Newlands · Prevention of Future Deaths report

On the 16th of August 2011 I commenced an investigation into the death of Laura Beth Newlands (DOB 31.1.1995 DOD 12.8.2011). The investigation concluded at the end of the inquest on the 27th of November 2015 and I recorded a conclusion of Suicide with the cause of death being 1(a) Trazodone Overdose

The Circumstances of the death are that the Deceased had been known to Denbighshire Social Services (DSS) as a result of referrals from her school and the Child and Adolescent Service (CAMHS) due to concerns relating to her self harming as a result of difficult home circumstances (DSS).

Although action was initially taken by DSS, her case was then closed and thereafter there was a delay in taking further action to provide support to her as a Professional’s Meeting was not arranged in a timely fashion and she took her own life by way of an overdose four days before the scheduled meeting.

1. Although a “safety plan” is prepared by CAMHS at the time of discharge from hospital, there does not appear to be sufficient input to this document by DSS with the result that those caring for a young person at risk may have incomplete written information available to them to properly ensure the safety of the young person.
2. A delay in scheduling an appropriate meeting of Professionals resulted in a missed opportunity to provide support and protection of a young person at risk and there was not therefore a prompt response to a crisis
3. The decision to close the case (and then not to reopen the same) by DSS resulted in there being no further assessments conducted at a time when action should have been taken and could have resulted in additional support for the deceased and her family. Such a decision may not have been made if the case had been reviewed by a senior staff member who was not directly involved in the investigation.