Anielka Agnes Grace Marie Jennings · Prevention of Future Deaths report

On the 12th February 2015, I commenced an investigation into the death of Anielka Agnes Grace Marie Jennings. The investigation concluded at the end of the inquest on the 15th June 2016. The conclusion of the inquest was a short form suicide with narrative conclusion. The medical cause of death was 1A - Vasovagal Inhibition as a result of 1B - Hanging.

This 17 year old young lady “Anielka” was diagnosed with cardiomyopathy in March 2010, aged 12 years and she suffered a stroke. She underwent a heart transplant in April 2010. Post procedure she recovered well from a cardiac perspective. However, she developed complicated neuro-psychological problems arising from the brain injury caused by the stroke. Anielka’s home life was difficult, and she was often reluctant to engage with professionals. She engaged in risk taking behaviours, which included on occasion self-harming, alcohol, illicit drug use, and becoming involved in inappropriate relationships. In December 2014, Anielka was taken off a child protection plan which had been in place since 2011. Her care was being transitioned from child and young person’s services to adult services. Multiple agencies were involved with Anielka’s care, and her complex needs were identified. However, no lead professional was identified to coordinate her care. On more than one occasion the agencies did not communicate with each other. This led to missed opportunities to provide a structured care plan for Anielka. In January 2015, Anielka drew on her bedroom walls a number of images which indicated suicidal intent. Local mental health services were not made aware of this. On the 4th February 2015, she attended her final appointment at the children’s transplant clinic. She travelled to Great Ormond Street with her father. Her journey was delayed by a fatality occurring on the railway line. She was also very upset after reading a report that referred to her ongoing need for support and services. The following day on the 5th February 2015, she left her father in Gloucester City centre at approximately 1000hrs. She made her way to her training college. She then departed for home. Her father returned home at about 1500 hours and found Anielka hanging by the neck from the banister. A dressing gown cord had been used as the ligature. Her father cut her down and dialled emergency services. Paramedics arrived shortly thereafter and pronounced Anielka deceased at 1510 hours. Police are satisfied there are no suspicious circumstances. A suicide note was found at scene.

(1) When an individual is being cared for by numerous agencies, in particular when said individual is a child transitioning to adult services, there is no lead/ key professional identified, which can result in a breakdown of communication between the agencies.