SOCIAL workers could have taken "simple steps" to save schoolgirl Dana Baker from hanging herself – and their failure to do so breached the teenager’s human right to life, a coroner has ruled.
There were failures at ‘every level’ of Worcestershire County Council’s children’s services systems after Dana was taken into foster care following revelations she had been sexually abused by her karate instructor, the Stourport inquest found.
Protective measures for the youngster – who had already taken an overdose and was known to pose a risk of self harm or suicide – were "almost non-existent" in the days leading up to her death in March 2011.
And Worcestershire Senior Coroner Geraint Williams said there was no coherent ‘one plan’ approach across the agencies involved in 16-year-old Dana’s care and the organisations did not abide by the systems that they had in place.
After the findings, Dana’s parents, Trevor and Patricia, said: “Throughout this inquest we have heard evidence showing that on the part of the agencies charged with Dana’s care there were a series of failings of communication, lack of consistent care and poor relationships between professionals, whose focus should have been on working together to protect Dana.
“We have heard very upsetting evidence about how in her last few hours Dana was asking for help.
“That help was not forthcoming. We will never know whether the outcome could have been different if Dana had got the support she was asking for.”
In his conclusions, Mr Williams said: “Her death was contributed to by a failure to have in place adequate measures to protect her from a known, present and continuing risk that she would kill herself.”
Stourport High School and VIth Form Centre A level student Dana, who originally lived with her parents in Hayes Road, Wolverley, was found hanging from a tree near the Worcester Road island in Kidderminster on March 3 2011.
Mr Williams, who concluded that she deliberately intended to end her own life, said children’s services failed to have in place a contingency plan when Dana’s placement with foster carers she had grown to call ‘mum and dad’ suddenly came to an end.
That had left social worker Liz Tune and her colleagues handling Dana’s case with nothing pre-arranged to turn to and they allowed a distraught Dana to stay with her friend, Mrs Sally King, over the two nights leading up to her death.
The coroner said Miss Tune had told him it was not practical to put in place constant supervision for Dana at this time of crisis – but accepted she could have asked Sally King not to let the youngster out of her sight and arranged for someone from social services to visit her daily.
The lack of advice, guidance and support given to Mrs King left her ill-equipped to protect Dana – and ‘there was an almost total failure to put in place protective measures for Dana and that this allowed her the opportunity to kill herself’.
“I find that not to put in place arrangements for this simple precaution was a significant failing,” said Mr Williams.
“I find the failure to have in place a contingency plan contributed significantly to the perilous position in which Dana found herself in early March 2011 because Elizabeth Tune and her colleagues had to deal with an urgent and sensitive matter with nothing re-arranged to which they could turn or upon which they could rely.”
He added: “I find that Dana was extremely vulnerable, the nature of the risk was a completed act of suicide, the magnitude of that risk was very great indeed and that the protective measures were almost non-existent.
“The evidence which I heard was very clear that Dana had previously been subject to crises but that, with input and help from her foster carers and the professionals working with her, those crises passed and her thoughts of suicide or self harm faded.
“I find that it would have been the simplest of measures, and well within the power of the local authority to have asked Sally King not to let Dana out of her sight and to arrange for visits on a daily basis by professionals in the immediate aftermath of March 2 2011, so as to allow Dana an opportunity to engage with Child and Adolescent Mental Health Services (CAMHS) and others, as she had so frequently done in the past.
“In my judgement these simple steps would have avoided Dana’s death on March 3 2011 and therefore I consider that Dana’s Article 2 (European Convention on Human Rights) rights were breached.”
The coroner is also sending a report to the Worcestershire Safeguarding Children Board highlighting his concern that agencies involved in Dana’s care had not shared each other’s independent management reviews on the case to learn lessons jointly.
The coroner found that there had been a flexible and 'wholly appropriate response by CAMHS to Dana's fluctuating state of mental health, which had helped her to overcome crises before.
But social services should have chased a response from CAMHS to messages left by social workers on the day leading up to Dana's death.
Mr Williams also rejected 'outright' an allegation that had been made by a former teacher at Wolverley CE Secondary School, which Dana attended when she made revelations about her sexual abuse, that the school had mishandled the situation.
"I find as a fact that the school and the individuals concerned acted with the utmost propriety and speed in referring the allegations to the police and social services," he said.
A large part of the evidence during the 12-day inquest at Stourport Coroner's Court focused upon suggestions by council social workers that Clare Baxendale, who was employed by the Child Care Bureau foster agency as social worker to Dana's foster carers, had overstepped her role.
Miss Baxendale had liaised constantly between Dana, her schools, CAMHS and the police to seek support for Dana at times of crisis - but that led to many of those involved failing to realise that she was not the teenager's social worker.
She had carried out a lot of the work for Dana that children's services should have been doing - and Mr Williams said he agreed with Siobhan Williams, Worcestershire's head of children's social care, that Miss Baxendale was a 'good social worker' and it was understandable that she stepped in to help Dana.
But her bosses at the Childcare Bureau, who were aware she was doing more than would normally be done by the foster carers' social worker, should have raised the matter with children's services.
This would have 'compelled children's services to have addressed its own shortcomings, which led to Clare Baxendale having to act in the way that she did', said Mr Williams.
Children's services had 'acquiesced' that much of its work was being done by others, said the coroner.
But he added: "I accept from the evidence that I was given that this was in part due to frequent changes of social workers and also periods when Dana did not have a social worker at all."