Ella Murray
7 Feb 2025 · Coroner Catherine Wood · Mid Kent and Medway
The coroner's concerns
1. child in complex family situation with mental health deterioration
“During the course of the inquest it became clear that [the deceased] was a child in a complex family situation and showing signs of deterioration of her mental health”
2. delayed safeguarding referral and removal from home
“This disclosure led to the nurse making a Safeguarding Referral but this was made after she left [the deceased]'s home and no urgent steps were taken to remove [the deceased] either to a hospital bed or to ask social services to consider if she should be removed from the family home”
3. inadequate risk assessment and denial of hospital admission
“Whilst there were concerns about the level of risk assessment undertaken on 14 November 2023 senior staff at the Trust gave evidence that she did not meet the criteria for admission to a hospital bed”
4. lack of mandatory information sharing duty
“It was brought to the court's attention that the new Children's Wellbeing and Schools bill includes a duty to share information to promote safeguarding”