ISABEL ANN RICHARDSON · Prevention of Future Deaths report

On 18 May 2015 I commenced an investigation into the death of ISABEL ANN RICHARDSON, AGE 12 YEARS. The investigation concluded at the end of the inquest on 26 AUGUST 2015. The conclusion of the inquest was Medical Cause of Death: 1(a) Hypoxic Brain Injury b) Cardiac Arrest c) Hanging and Conclusion: Isabel Richardson took her own life. Her intention at the time was not known.

Isabel’s mother died in 2010. Isabel started at Hewett High School in September 2014. In April 2015 Isabel was found to be self-harming by cutting her arms and legs. She told school staff and her father she was missing her mother and her step-mother. She was referred to Nelson's Journey Charity and a Counsellor for help. The school were telephoned by a parent of a concerned friend after seeing pictures posted on social media, informing them of Isabel self-harming. On the morning of Isabel's death the school were again telephoned by a parent about a post made by Isabel on social media indicating she may kill herself. The school contacted Isabel's father and indicated the appointment with Nelson's Journey would be chased up. Isabel had failed to attend one appointment with the Counsellor. It was not clear from the evidence why this was. An appointment was made with the Counsellor for the next day. It was not clear from the evidence Isabel had been made aware of this.

(1) A Pastoral Team were in place at the School but it was not clear from the evidence as to their purpose, how they worked or whether they were trained in the role they were expected to perform;

(2) It was not clear that the Pastoral system was robust or structured enough to deal with the problems that Isabel presented.