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Investigation and inquest
On 10 January 2013 I commenced an Inquest into the death of Helena Kathleen Farrell, date of birth: 20 February 1997. The investigation concluded at the end of the inquest on 30th June 2014. The conclusion of the inquest was that she died as a consequence of her own actions though her intention is not clear beyond unreasonable doubt. The cause of death was 1a. Hanging.
Circumstances of the death
Helena suffered from bulimia and had been assaulted sexually whilst on a school exchange visit. This occurred during 2011 and the incident probably occurred in France. During October 2012 to January 2013 a number of events occurred including that she revealed the fact she was bulimic and the fact she had been assaulted, she took an overdose, self-harmed at a party, and wrote a number of letters which when read after her death appeared to have been suicide letters. Although she was referred by the School Nurse to Child and Adult Mental Health Services (CAMHS) she was not seen until the day before she died and no-one who saw her thought that she was suicidal and everyone who had dealings with her seems to have misunderstood her true feelings and intentions.
Coroner’s concerns
(1) As for CAMHS (part of the Foundation Trust) the referral system was not working adequately and the referral was not followed up after triage even though it was classified as urgent.
(2) Staffing levels at CAMHS were inadequate in terms of pure numbers and also in terms of experience and training in connection with teenagers.
(3) Those dealing with Helena failed to recognise the escalation of the incidents in which she was involved in terms of their seriousness and their increasing frequency.
(4) As far as Cumbria County Council is concerned, they are involved because I understand they are responsible for provision of the school nurse service although they contract this out to the Partnership Trust but nonetheless the responsibility lies with Cumbria County Council. I thought that the expectations of the school nurse in this particular case were totally unrealistic. I heard in evidence that she was responsible for 5 senior schools and 20 or more feeder schools to those 5 senior schools and although the total number of pupils involved was not clear, it is obviously thousands rather than hundreds. She worked a 26 hour week, had 40 current cases at Kirkbie Kendal School alone. The provision of service at this level is totally unfair on the school nurse concerned, unrealistic in the sense that she seems to have expectations of a school nurse which one part time provider cannot meet.
(5) The school’s counsellor had been in post for many years and there was no proof of her qualifications or her competence nor of update and training or registration with any professional body. The County Council needs to be more thorough with checking credentials.
Information checked against the published report and official responses