A CORONER has told an inquest he will write to two Cumbrian health agencies to ask them to ‘think and reflect’ on future practice.

Ian Smith told a hearing into the death of Kendal teenager Helena Farrell that he would write to both the Cumbria Partnership NHS Foundation Trust, which runs the children’s mental health service CAMHS, and to Cumbria County Council (CCC), which operates the school nursing system.

“The only conclusion I can give to the parents is to try to highlight problems and then to say to various organisations ‘please consider this, please’,” he said.

“I can’t make them do anything but I can ask them to think and reflect and I will be doing that.”


He told the court that CAMHS (Child and Adolescent Mental Health Service) was ‘not functioning at all’ in the weeks before Helena, 15, hanged herself.

The teen was found dead in January, 2013 - a month after seeking help for ‘dark thoughts’ and bulimia, which she had been suffering ever since being sexually assaulted 18 months previously.

Despite being ‘triaged’ by the service as ‘urgent’ she was not formally assessed until just 24 hours before her death, after the service was contacted by her mother, Maria Farrell.

“When you really look at it objectively they didn’t actually do anything about it at all until January 2 when Mrs Farrell rang to see what was going on and was then offered an appointment,” said Mr Smith.

“But nothing effective had happened up to that point.

“So although it was triaged as urgent it was not dealt with urgently.”

Mr Smith said the service was being dogged by low staff morale at the time.

He said it was ‘under-staffed’ and the staff it had was ‘not experienced enough’.

He described information sharing as ‘poor’ and said changes to leadership had also played a part.

“Organisation was poor and there was a lot of sickness among staff and not surprisingly low morale.”

He added: “Not surprisingly it wasn’t functioning at all.”

He now plans to ask CAMHS to look at its staffing levels and referral system to ensure no future patients are ‘overlooked’.

He will also write to CCC after the school nurse system was also criticised for making one nurse, Donna Moore, responsible for the welfare of students at five secondary schools - including Helena’s Kirkbie Kendal School - and around 20 primary schools.

“I think it was an unfair burden on Donna Moore,” said Mr Smith.

“I will be asking that regular checks be made.”

He also said he would ask the police to look into the alleged sexual assault, which took place in France while Helena was on an exchange trip abroad.

The Kirkbie Kendal School pupil had first sought help on December 3, 2012, telling teacher, Mike Bousfield, about the bulimia and sexual assault.

That night she took an overdose of paracetamol.

She also self-harmed on at least one other occasion, after scratching herself with scissors at a party.

The court also heard that Mr Bousfield was given a series of ‘suicide letters’ written by Helena - but he put these, unopened, in the school’s safe.

He claims school counsellor, Siri Morgan, later told him to ‘bin them’.

“Siri’s exact words were ‘she’s not suicidal’,” said Mr Bousfield.

“She was adamant she wasn’t suicidal.”

Helena was found dead on January 4, 2013, in woodland behind the Castle Green Hotel, Kendal.

Mr Smith concluded the four-day hearing by saying Helena had died ‘as a consequence of her own actions’, although ‘her intention was not clear beyond reasonable doubt’.

A Serious Case Review has since been carried out and the results were released this morning.

Sara Munro, director of quality and nursing for Cumbria Partnership NHS Foundation Trust, said: “There was an unacceptable delay in her being seen by the CAMHS service and we have made significant improvements to that service.

“Everyone has an important role to play in safeguarding the emotional health and wellbeing of young people and only by working together can we reduce the chances of this happening in the future. I would encourage everyone to take note of the signs to look out for and how to get help as early as possible.”