Philip Rule KC was instructed by Will Whitaker of Bindmans Solicitors, assisted by Carmen Hall, to represent the family of a girl who was in the care of the local authority and mental health services at the time she died aged just 17. Jasmine had been in care from the age of 12, and was known to have mental health vulnerability, which at times had led to her being placed into hospital.

HMAC J. Taylor heard the inquest over a two-week period and handed down his findings and conclusion after careful deliberation on 22 August 2023. He found that Jasmine died as a result of accident.  She was in a state of mental crisis and did not freely intend to take her own life.

Jasmine had a history of mental illness, and had suffered complex trauma (including sexual exploitation as a teenager). She had multiple admissions to hospital (including under the Mental Health Act). She had been in care since a young age, and a Looked-After Child since 10 February 2015. In that time in care she lived in at least 18 placements, all over the United Kingdom, and often moved large distances from any friends or family. The inquest heard evidence from a former Service Manager for Social Work with Children Looked After and Care Leavers at the London Borough of Croydon that there is “a national crisis” in the available placements for young people to discharge the statutory duties of care local authorities owe to vulnerable children.

Jasmine was outside of mainstream education since the age of 12, and was not in any steady or continuing employment at the time of her death. Neither the South-West London and St. George’s Mental Health NHS Trust’s mental health team nor the London Borough of Croydon’s social work team supported Jasmine after court on 4 March 2020 when she was in a vulnerable state, and called 999 seeking help before she died.

Jasmine’s family was concerned at the failings of the services that Jasmine was under the care of, and turned to for help, to provide her with the necessary and appropriate care and support. The coroner found that a long list of failings had contributed to her death, or may have contributed to her death. In particular there was:

i. Failures of the Adolescent Outreach Team (“AOT”, of the South-West London and St. George’s Mental Health NHS Trust):

a. Failure of the AOT’s risk assessment to provide for an adequate formulation of risk-to-self for Jasmine (including impulsive responses, and increased anxiety when attending criminal justice proceedings, loss of employment, drug debts, fear of child sexual exploitation) and a risk management plan consciously directed to meet that formulation.

b. Failure of the AOT to review and update the risk assessment at the Care Programme Approach meeting on 3 March 2020, thus not remedying the existing inadequacies, and not considering the February 2020 incidents and behaviour in relation to risk that Jasmine posed to herself.

c. Failure by the AOT, as an attendee at the CPA on 3 March 2020, to identify the forthcoming dates for court appearances that Jasmine had – thus not recognising and planning for supporting her at and around her court attendances on 4 and/or 5 March 2020. There was an absence of clear communication lines or of recording of such dates.

ii. Failures the London Borough of Croydon was responsible for:

(a) An absence of maintained knowledge/fragmented response over Jasmine’s time in care

(b) Inadequate accommodation generally

(c) Failure to instigate and implement a plan for Jasmine’s longer-term needs

(d) Not taking the role of lead agency in the care planning for Jasmine

(e) Failure to identify the forthcoming dates for court appearances that Jasmine had

(f) Failure to support Jasmine at court on 4 March 2020.

An earlier stage of the proceedings was reported here:

Philip Rule KC is head of the public law group at No5 Chambers, which has offices in London, Bristol and Birmingham.