A MENTAL health organisation has undergone a complete shake-up after a schoolgirl hanged herself, despite being referred as an emergency case.
The notes regarding Lowton High School pupil Poppy Bracy, 13, went missing and were not found until after her death, an inquest heard.
She was found hanged from her bedroom door by foster carers Karen and Steve Riley at their house in Bridgewell Drive, Leigh, on March 1 – a month after being identified as high-risk of self harm by school nurse May Woodcock, and being referred to the Children and Adolescent Mental Health Service (CAMHS) as an urgent case.
Bolton Coroner’s Court heard that, although urgent cases had to be actioned within 24 hours, Poppy was not seen at all because her case documents were lost.
The file was put into the wrong cabinet, and was only discovered after her death. It was also found, during an internal investigation, that the teens’ case had been closed on the computer system a week after the referral was made.
As a result of Poppy’s death, an independent multi-agency review board was launched and five recommendations were made to the organisation, which is part of the Five Borough’s Trust.
Coroner Jennifer Leeming said: “The CAMHS policy was that such a referral should result in contact being made with the family or the carers within 24 hours, and that wherever possible, the child should be seen by CAMHS within 24 hours of a referral being received.
“Contact was not made within 24 hours or at all, and Poppy was not seen within 24 hours or at all in relation to this referral.”
Mrs Leeming recommended at the conclusion of the three-day inquest that a system should be introduced, allowing social workers to follow up referrals.
She also noted that an unidentified member of staff from Lowton High School had been told of a previous attempt Poppy had made to hang herself, but did not follow correct procedures.
She said: “The policy of the school was that such information should be passed to a child’s parents or carers. That information was not passed on to her mother, her carers, nor her social worker.”
She added: “I am satisfied that action is being taken to address precautions that could be placed into being in an endeavour to avoid anything of this kind happening again, through the CAMHS review procedure.
“I am also satisfied that there is nothing further that Poppy’s school need to do to ensure staff are aware of their responsibilities.”
At the time of Poppy’s death, classmates posted comments on a Facebook tribute site, which suggested she was being bullied. This sparked a police investigation.
Robert Tonge, who was Divisional Detective Chief Inspector at the time, said: “There is no evidence at all that Poppy was being bullied, we’ve checked her diary, interrogated her phone, spoken to her friends, I’ve addressed the year group at her school and have spoken to her foster carers and her mum, and have found no evidence.”
In the days before her death, Poppy seemed positive and was looking forward to the future, which included possibly moving into a children’s home in Hindley.
A Nintendo DS games console was also found on pause on her bed when her body was discovered.
The coroner recorded a verdict of accidental death by hanging.
She said: “Mr Riley told me in his evidence that Poppy was so beautiful, caring, loving and intelligent. Tragically, and touchingly, he said she could have done anything with her life.
“She had so much potential, and I’m so sorry this has happened. It’s clear you all loved her very much.”
Following the inquest, a joint statement on behalf of Wigan Council, Five Boroughs Partnership and Lowton High School, said: “The death of Poppy Bracey was a tragedy, and all our thoughts and sympathies remain with those who were closest to her.
“The coroner has delivered her verdict that Poppy’s death was an accident, and she did not intend to take her life. The coroner was satisfied that the Child and Adolescent Mental Health Service (CAMHS) and the school have policies in place to safeguard children.
“She has made one recommendation to the council to ensure that there is an audit process in place to track referrals made the CAMHS service.
“Work is under way to strengthen the working practices between CAMHS and Children’s Social Care, and the audit process will be incorporated into this.”
“Concurrent to the coroner’s hearing, we can confirm that internal investigations are under way.”