Nikolas Clarke represented a local authority at the Article 2 inquest into the death by suicide of JD, a vulnerable 17-year-old girl.
JD had a history of mental health issues and had been a ‘looked-after child’ in the local authority’s care since 2015.
In early March 2020 paramedics found her unresponsive in the toilets at Fairfield Halls in Croydon. She was pronounced dead at the scene.
On the day of her death, JD had been due to appear at the local magistrates’ court.
Her family were critical of the care JD had received and that they believed contributed to her death.
The coroner recorded a narrative verdict of 'accident'. He concluded that JD did not freely intend to take her own life but was in a state of mental crisis at the time of her death.
He listed a range of contributing factors including her:
• drug-induced psychosis, paranoia, delusional belief, distress and emotional dysregulation, and complex trauma
• substance misuse
• mental health breakdown: she had had multiple admissions to hospital (including under the Mental Health Act)
• violence, aggression and criminal damage (with involvement from the police, and for which charges against her had been brought)
• being outside mainstream education since the age of 12
• not being in steady or continuing employment
• difficulties in relationships with others
• being in care since a young age
• having lived in at least 18 placements (including 5 which were secure accommodation, under court orders)
• recently having had a change of social worker.
He found that other matters may have contributed to JD’s death including:
• her non-compliance with medication and non-engagement with services
• the local authority’s absence of maintained knowledge/fragmented response during JD’s time in care
• inadequate accommodation generally
• the local authority’s failure to instigate and implement a plan for JD’s longer-term needs
• the local authority not taking the role of lead agency in the care planning for JD.
No report to prevent future deaths was made.