A coroner will write to the Secretary of State for Health and Social Care about the increase in children seeking mental health support after a 12-year-old girl took her own life.
Andrew Hetherington said he will contact Therese Coffey after hearing, during the inquest of Charley Ann Patterson, about the increase in the number of children presenting in hospital for self-harm and anxiety.
The inquest into her death heard how Charlie hanged herself at her home in Cramlington, Northumberland, after being bullied. She was found unresponsive in her bedroom by her dad Paul and and passed away in hospital on October 1, 2020.
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Northumberland Coroner's Court heard how a workbook in her bedroom contained notes which said: "I'm going to kill myself" and "It will be quick, one more step". A television was also paused on a screen which said "Am I a misfit?".
During four-day hearing, the court heard how the number of children being referred to mental health services for their emotional wellbeing had increased from one a week to one a shift.
The Senior Coroner for North Northumberland and Acting Senior Coroner for South Northumberland said he would write to Ms Coffey about the matter. He told the court: "It’s my intention to write to the Secretary of State for health and social care, to write about the concerns I have heard."
The inquest, sitting at County Hall in Morpeth, Northumberland, heard how Charley had previously reached out to health services after self harming on two occasions. She suffered from low mood and anxiety related to a number of factors including covid-19 lockdown restrictions, friendship difficulties with peers and other influences.
Charley visited her GP with her mum Jay in June 2019, after self harming for the first time. The court heard how she was told to write her thoughts and feelings in a diary, which she did. In a statement, Jay said: "I do not believe the GP took Charley's self harm seriously, particularly due to her age."
The youngster was admitted to Northumbria Specialist Emergency Care Hospital in Cramlington in May 2020 after harming herself for a second time. Charley told a nurse how she had been bullied online and she couldn't speak to her friends to reconcile due to being at home during the coronavirus lockdown.
The inquest heard how Charley was assessed by a mental health nurse who identified that she had anxiety and low self esteem and a plan was made to refer her to the Northumberland early help hub. However the referral to hub was never processed by the trust.
The coroner told the court that he was satisfied that, on both occasions, Charley, who attended Cramlington Learning Village, did not meet the criteria for a referral to the Children and Young Person's Service.
A statement from Charley's mum, which was read to the court by the coroner, revealed how her daughter has been sent a message which said "You're useless, you can't even kill yourself properly".
She said that, just a week before Charley died, her daughter was sent an alarming video which showed her how to tie a knot. She said: "She would not tell me who had sent this to her but she was visibly upset by it."
The coroner said: "It’s evident to me in the period leading up to Charley’s death she had been suffering from bullying."
He said that it was likely that messages, videos and comments would have had an impact on Charley. He said the bullying had taken place "overwhelmingly by electronic devices" and had likely taken place outside of school.
The coroner said that, following Charley's death, a safeguarding investigation was carried out and safeguarding standards had been met by her school.
During his conclusion, he listed a number of concerns which included a no contact being made with the local authority in the previous area, a letter not being sent to her GP and a referral to the Northumberland early help hub not being made by the assessment team.
The inquest heard how it was wrongly assumed that a referral had already been made when it fact it was to be made after the follow up appointment. Coroner Hetherington said: "It’s not possible to say, if those steps had been undertaken, whether the outcome would have been any different."
Northumbria Police identified that Charley had been bullied and offences, such as malicious communication and harassment, were considered by the force. However none of the incidents crossed the threshold for prosecution. During his evidence, Detective Sergeant Lee Baldwin, told the court: "In conclusion, there's nothing to suggest that it is anything other than suicide."
During the inquest, Pathologist Dr Nigel Cooper told the court that he believed Charley died as a result of pressure to the neck as a result of hanging. He said there was nothing to suggest any third involvement and no evidence of natural disease. The coroner said: "I accept Dr Cooper’s opinion as the the cause of death."
The coroner concluded that Charley died as a result of suicide.
Rajesh Nadkarni, Medical Director and Deputy Chief Executive said: "Our hearts go out to Charley’s family at this incredibly difficult time. The death of a child is something no parent should face.
"We have made improvements and every child assessed is now discussed at daily multi-disciplinary meetings ensuring that all recommendations are actioned including those involving risk and safeguarding.
"We welcome the coroner’s intention to write to the Secretary of State for Health and Social care acknowledging the increasing pressure mental health services are experiencing."
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