A CORONER has called for changes after health professionals failed to realise that a troubled Kendal teenager was suicidal.
Summing up at the inquest into the death of 15-year-old Helena Farrell, South Lakes coroner Ian Smith said that ‘various organisations’ should learn lessons from the tragedy and reflect on what had happened.
The inquest heard that Helena first sought help on November 30, 2012 – more than a month before she was found hanged in a Kendal wood – and went on to self-harm on at least two more occasions before her death.
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On one occasion she took a paracetamol overdose and on another she cut herself after seeing her ex-boy-friend kissing another girl.
The Kirkbie Kendal School pupil also wrote several ‘suicide letters’ which she handed over to English teacher Mike Bousfield.
These were put, unopened, in a school safe. Days later, school counsellor Siri Morgan told Mr Bousfield to simply ‘bin them’.
“Siri’s exact words were: ‘She’s not suicidal’,” said Mr Bousfield. “She was ada-mant Helena wasn’t suicidal.”
The talented cellist, singer and hockey player revealed for the first time a month before her death that she was suffering from ‘dark thoughts’ and bulimia, which she said had begun following a sexual assault on an exchange trip in 2011.
Days later she turned to the school counsellor, a school nurse, her GP and the Child and Adolescent Mental Health Service (CAMHS) for help.
None realised she was at risk of killing herself – and Mr Smith told the inquest that CAMHS was ‘not func-tioning at all’ at that time.
He said as an urgent case, Helena had been ‘triaged’ - a process to decide order of treatment for patients - but she was not formally assessed until just 24 hours before her death, after the service was contacted by her mother Maria.
“When you really look at it objectively they didn’t do anything about it at all until January 2, when Mrs Farrell rang to see what was going on and was offered an appointment,” said Mr Smith.
“But nothing effective had happened up to that point.
“Although it was triaged as urgent, it was not dealt with urgently.”
Mr Smith said the service was dogged by low staff morale at the time and was ‘under-staffed’ – and the staff it had were ‘not experienced enough’.
“Organisation was poor and there was a lot of sickness and, not surprisingly, low morale,” he said.
“Not surprisingly it wasn’t functioning at all.”
He also criticised the school nursing system after hearing that Kirkbie Kendal nurse Donna Moore, had responsibility at the time for the welfare of around 5,000 pupils across five secondary schools and at least 20 primary schools.
He told the hearing he planned to write to both the Cumbria Partnership NHS Foundation Trust, which runs CAMHS, and Cumbria County Council (CCC), which operates the school nursing system, to ask them to consider the way they operate.
He also said he would ask the police to look into the alleged sexual assault, which took place in France.
The hearing concluded that Helena had died ‘as a consequence of her own actions’, although her intention was not clear beyond reasonable doubt’.
Her body was found in woodland behind the town’s Castle Green Hotel in the evening of January 4.
At the scene were 14 sheets of paper with various words on them, shells and a bundle of clothes, while a song by band Coldplay was playing on a continuous loop.
Helena had earlier attended The Windermere School and was a high achiever in sports and the arts.
“Helena had such a lot to live for,” said Mr Smith. “She was talented, intelligent, gifted naturally in music, performing arts, sport, academically bright, not a rebel, compliant, helpful, nice with parents and with teachers.”
The coroner went on to praise the young people who acted to help Helena Farrell in the weeks before her death.
He hailed Helena’s friends, and in particular her former boyfriend, Billy Williams, and said they had been ‘responsible and sensible’ by passing on information they learned about her mental state.
“Her friends did not get information and keep it to themselves,” he said.
“They realised that the information they were getting could have been serious and were extremely responsible and sensible in sharing that with adults and getting something done about it.”
Mr Williams’ parents later praised their son for doing ‘the right thing’ by trying to help Helena.
'LET DOWN AND BETRAYED' SAYS FAMILY
THE parents of Helena Farrell have hit out at the mental health service that ‘failed’ their daughter.
Enda and Maria Farrell spoke out at the end of the inquest revealing how ‘let down and betrayed’ they felt by the professionals who failed to spot how ill she was – despite concern expressed by both Mr Farrell and Helena’s friends.
“We believe that had Helena had the opportunity to see an experienced and empathetic psychotherapist early in December 2012, her distress may not have escalated to her acting,” they said.
“We were unable to find help for Helena outside of the NHS and were thus entirely dependent on the health service to provide this type of intervention.
“We feel let down and betrayed by the failures of teachers and health profes-sionals who dealt with Helena.
“They failed to be con-cerned enough to urgently seek help for her from mental health professionals with appropriate expertise. No-one even once made a telephone call to discuss her presentation with a duty mental health professional.”
They admitted they had been ‘shattered’ by the tragedy and now believe that at the time of her death Helena believed she was ‘doing the right thing’.
They added: “We hope that Helena’s story will inspire professional and non-professional people to reflect on how we all deal with young people with emotional distress. We all can improve our awareness of the risks of suicide in young people and how to intervene.”
The family now supports national charity PAPYRUS, Prevention of Young Suicide.
POOR PRACTICE AND BAFFLING FAILURES
A REVIEW carried out following Helena Farrell’s death uncovered ‘poor practice’ and ‘baffling’ failures by those she turned to for help.
The Serious Case Review put together by Cumbria’s Local Safeguarding Children Board found professionals from all agencies failed to recognise the extent of her problems and risk of suicide.
“At its heart this is a case of an able, high achieving young person with apparently every-thing to live for who took her own life, despite the best efforts of her parents and those professionals who were closest to her to keep her safe,” said the report, which refers to Helena as ‘Child J’.
The report presented nine findings based on evidence from teachers, health workers and Helena’s parents.
These include that several people involved were ‘ill-equipped’ to deal with teenage suicide, that they drew ‘naive’ and ‘simplistic’ conclusions about Helena and that many assumed she would only be suicidal if she appeared ‘depressed’.
The report also repeated a lot of what was reported at the inquest, including the issue of Helena’s ‘suicide’ letters being in a school safe unopened.
The report said: “The decision not to open the letters appears baffling. It seems incomprehensible that the staff involved did not override Child J’s wishes (for them not to be opened) and seek immediate expert advice.”
The report concluded that the findings might be ‘painful to hear’ and that solutions to problems will not necessarily be easy to find.
“Nonetheless,” it adds, “it is important if Cumbria is to become a safer place for children to live for the board to embrace the findings of the review and take steps to address the issues identified.”
TIMELINE TO A TRAGEDY
May - July 2011: Helena goes on an exchange trip to Germany and, as part of that, spends a week in France. During this week she is sexually assaulted by an older man
September 2011: Helena leaves Windermere School and begins studying at Kirkbie Kendal School
October 22, 2012: She begins a short relationship with local boy Billy Williams, who leaves her ‘heartbroken’ when he breaks up with her
November 30, 2012: Helena and now ex-boyfriend Billy reveal to teacher Mike Bousfield that Helena was sexually assaulted and has been suffering from bulimia ever since
December 3, 2012: Mr Bousfield refers her to the school nurse. That night she takes an overdose of paracetamol, saying she ‘wanted it all to go away’
December 4, 2012: School nurse Donna Moore meets with Helena’s parents. She says she will refer Helena to CAMHS. Meanwhile Helena is referred to school counsellor Siri Morgan
December 9, 2012: Billy’s father, also Billy Williams, contacts Mr Bousfield at home, saying there have been ‘worrying’ text messages from Helena
December 10, 2012: Helena is referred to CAMHS by Donna Moore
December 13, 2012: Helena visits her GP at the Captain French Lane surgery, where she is assessed as being a low suicide risk. Her case is triaged at CAMHS for the first time and she is assessed as an ‘urgent’ case
December 15, 2012: Helena goes to a party. She self-harms with scissors after Billy is seen kissing another girl
December 16, 2012: She tells Billy she has written ‘some letters’
December 17, 2012: Billy and another friend tell Mr Bousfield that Helena has written the letters, which he finds in her bag. Her parents are informed and the letters are put, unopened, in the school safe
December 19, 2012: Ms Morgan tells Mr Bousfield to ‘bin’ the letters
December 28, 2012: Helena’s case is triaged for a second time at CAMHS
January 2, 2013: Mrs Farrell contacts CAMHS and asks for an update. She is offered an appointment in Kendal the following week or in Barrow the next day. She takes the appointment in Barrow
January 3, 2013: Helena is assessed at CAMHS in Barrow by social worker, Anna Wiodarczak, who also failed to spot Helena was at risk of suicide
January 4, 2012: Helena is found hanged behind Kendal’s Castle Green Hotel