Tragic Derbyshire schoolboy failed by a '˜disjointed and dysfunctional system'

Dr Robert Hunter said all had previous dealings with Joe before his death and failed to pass on information to detectives or child protection officers. Joe’s inquest heard he had been buying drugs from an unregulated part of the internet known as the “dark web”. Despite taking a form of LSD into his school, police were not alerted. Six months later Joe died when he took heroin he had paid for online.

In his narrative conclusion to the inquest yesterday, Dr Hunter said: “Joseph William Southam, who suffered from low mood and anxiety, died as a consequence of risk-taking behaviour in which he would experiment with known drugs and other chemicals he had researched and acquired from the internet.

“His death was in part contributed to by a number of agencies he was in contact with, not appreciating that he was a child at risk and consequently, despite a significant number of opportunities to do so, no safeguarding referral was made. As a result of no safeguarding referral being made, no effective measures were put in place to protect him from harm. Dr Hunter told Joe’s family he would write to them next week outlining to them in detail the full reasons why he reached the conclusion that he did.”

Earlier, Dr Hunter, Senior Coroner for Derby and Derbyshire, had slammed an already damning report which concluded there was “a lack of child protection and a lack of information sharing” between medical professionals that were seeing Joe in the lead up to his death. Dr Hunter said he was “sick to death” of reading how deaths “could not be predicted or prevented” as he challenged the report’s conclusion that medical professionals “could not have predicted” the 15-year-old would die.

The report, commissioned by Children and Adolescent Mental Health Services (CAMHS) in Derbyshire, was described as “uncomfortable reading” by Dr Hunter. Its author Joanne Kennedy, a consultant child and adolescent psychiatrist, said agencies were “working in isolation” in their treatment of Joe, who died following a heroin overdose in July 2014.

In the months before he died he was attending on-off voluntary appointments with CAMHS and his drug taking was well known to his general practitioner and his family. He had also been temporarily excluded from school after he sold an LSD-style “legal high” to a fellow pupil that left the boy hospitalised.

Dr Hunter said to Ms Kennedy: “How can you conclude his death could not have been predicted when he was being managed in a disjointed and dysfunctional system? All the people that saw Joe explained to him the serious risks he was putting himself under by buying drugs and taking them. It was pointed out to him that he could die and that’s exactly what happened.

“I am sick to death of hearing that deaths cannot be prevented or predicted but in this case there have been serious failings in the clinical acumen or those involved were wilfully blind to the facts. This was crying out for (the involvement of) social services.” Ms Kennedy replied: “Yes, I would agree.”

Joe was described as “an outstanding talent” by Anthony Gell School, Wirksworth. On July 31, 2014, his mother Barbara found him on his bed at their home in Canterbury Terrace, Wirksworth, and called the emergency services. Joe was airlifted to the Royal Derby Hospital where he was declared dead later the same morning.

His inquest at Derby and Derbyshire Coroner’s Court this week heard how the teenager had been able to spend around £1,000 on drugs he bought on the so-called dark web – a hard-to-find part of the internet where illegal substances can be purchased online. The hearing was also told how he would interact with other drugs users on internet forums.

Dr Hunter said: “I have found a number of failures in the way he was managed by a number of agencies and it is lamentable these failings were so extensive.”Taking it agency by agency: Mental health services, I find it as fact they failed to appreciate Joseph was a child at risk and that with him there was not just a risk of harm in what he was known to be doing but a risk of death.

“Staff were isolated with no clinical support or supervision and communication was inadequate and positively dangerous. Their support for his drug use and anxiety was treated separately saw them absolve themselves when both conditions should have been treated concurrently. They had multiple opportunities during their contact with him to refer him to social services for safeguarding. Overall I would say that children’s mental health service was disjointed and dysfunctional.”

“The children’s emergency ward at the Royal Derby Hospital (there was an episode a number of months before he died when Joe was taken there after taking a cocktail of drugs and alcohol), they explored his physical condition but they failed to recognise his obvious mental health issues.

“Anthony Gell School failed to follow imperative direction (rules) and report Joe to social services as a safeguarding issue and failed to follow imperative direction of their misuse of drugs policy by not reporting him to the police. By not following this the school attempted to minimise itself from the issues.

“His general practice should have referred Joseph to social services and Dr Penny Blackwood, his GP, admitted that in evidence herself. Uniformed police did not address previous issues with Joseph and make CID or the child protection unit aware of what was happening.

“None of the agencies directed their minds to Joseph’s family unit which was under considerable pressure.Having considered all of the evidence and the magnitude of the failings I find it as fact that had there been a developed and focused care plan in place then, on the balance of probability, Joseph would not have died when he did.”

John Sykes, medical director of Derbyshire Healthcare NHS Foundation Trust said: “The Trust extends its deepest sympathies and condolences to Joe’s family and friends at this difficult time. The safety and wellbeing of the people who use our services is of paramount importance, and we are sorry that the care we provided to Joe fell short of the standards expected.

“As outlined at the inquest, we have put in place a number of improvements since Joe’s death in 2014 and will continue to do so to ensure that lessons are learned throughout the organisation. These actions include providing higher levels of child protection training to our staff, equipping staff working in our mental health services with the skills to respond more effectively to those who also have substance misuse issues, and educating staff to understand the importance of sharing information with relevant professionals both within the organisation and at partner agencies.

“We have recruited an additional consultant psychiatrist and realigned our medical and nursing staff in the south Dales area to enable much closer collaborative working. We are also focusing on our wider safeguarding processes to ensure that the improvements made are sustained and further developed.”

Malcolm Kelly, who has been head teacher at Anthony Gell since September last year, said: “Joe’s tragic death affected the whole school and our thoughts have particularly been with his friends and family this week during his inquest. We have contributed to an ongoing Serious Incident Learning Review being carried out by Derbyshire Safeguarding Children Board which will consider the Coroner’s findings and we will ensure that any recommendations are fully implemented within the school.”