R (Joanne Patton) v HM Assistant Coroner for Carmarthenshire and Pembrokeshire
| Jurisdiction | England & Wales |
| Judge | Mrs Justice Hill |
| Judgment Date | 07 June 2022 |
| Neutral Citation | [2022] EWHC 1377 (Admin) |
| Court | Queen's Bench Division (Administrative Court) |
| Docket Number | Case No: CO/3451/2021 |
and
[2022] EWHC 1377 (Admin)
Mrs Justice Hill
Case No: CO/3451/2021
IN THE HIGH COURT OF JUSTICE
QUEEN'S BENCH DIVISION
ADMINISRATIVE COURT IN WALES
Cardiff Civil and Family Justice Centre
2 Park Street, Cardiff, CF10 1ET
Christian Howells (instructed by Watkins and Gunn solicitors) for Ms Patton
Sebastian Naughton (instructed by Pembrokeshire County Council Legal and Democratic Services) for the Defendant
Malcolm Duthie (instructed by Dolmans Solicitors) for Pembrokeshire County Council
James Berry (instructed by Hywel Dda University Health Board Legal Services) for Hywel Dda University Health Board
Hearing date: 4 May 2022
Approved Judgment
I direct that pursuant to CPR PD 39A para 6.1 no official shorthand note shall be taken of this Judgment and that copies of this version as handed down may be treated as authentic.
Covid-19 Protocol: this judgment was handed down by the judge remotely by circulation to the parties' representatives by email and release to The National Archives. The date and time of hand-down is 10.30am on 7 June 2022
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Introduction
This is a claim for judicial review brought by Ms Joanne Patton, the mother of Kianna Patton who died on or around 23 October 2019 when she was 16 years old. Her body was found hanging in an abandoned hotel on that date.
At the time of her death Kianna was under the care of Specialist-Child and Adolescent Mental Health Services (“S-CAMHS”). She was living with a friend, whose mother had let her use cannabis. This caused Ms Patton significant anxiety given Kianna's mental health issues. She sought assistance in relation to Kianna from social workers and Police officers before her death. She believes there were serious failings in the way they responded and in the care S-CAMHS provided to Kianna.
An inquest was duly opened into her death. Pembrokeshire County Council (“the Council”), Hywel Dda University Local Health Board (“the Health Board”) (which is responsible for S-CAMHS) and the Chief Constable of Dyfed Powys Police (“the Police”) were granted Interested Person status in the inquest proceedings and are thus Interested Parties in this claim.
By this claim Ms Patton challenges the Coroner's ruling dated 8 August 2021 to the effect that the inquest into Kianna's death will not investigate in what circumstances she came by her death, pursuant to section 5(2) of the Coroners and Justice Act 2009, because the procedural investigative duty contained in Article 2 of the European Convention on Human Rights (“the Convention”) did not arise. On 24 November 2021 she was granted permission on all her three grounds by Upper Tribunal Judge Grubb, sitting as a judge of the High Court.
The Council played an active role in the proceedings, defending the Coroner's decision. The Health Board remained neutral on the first two of the Claimant's grounds but made some limited submissions on the third. The Coroner took a neutral stance in responding to the claim but provided written and oral submissions intended to assist the court, particularly in understanding the approach he had taken in reaching his decision. I was greatly assisted by the submissions from all counsel. The Chief Constable remained neutral on the claim and placed no submissions before the court.
I reiterate my condolences to Ms Patton and her family for their tragic loss. As in any case of this nature it has been necessary to make difficult decisions based on a complex and nuanced legal framework, but at the heart of the case remains the death of a vulnerable child and a grieving family.
The facts
Kianna was born on 22 June 2003. She was one of three children. Ms Patton's evidence is that she generally performed well at school as a young child. Difficulties appear to have emerged in 2017. Kianna went missing on more than one occasion. It appears that in June 2017 she took an overdose but did not tell anyone about it.
At around the beginning of 2018, Ms Patton noticed that Kianna's behaviour had started to change, particularly after she started using drugs, having become friends with other children who did so. Kianna started missing school and her grades began to fall.
On 26 January 2018 Kianna was referred to S-CAMHS by her GP as she had disclosed self-harm with a razor blade and was experiencing panic attacks and low mood. She was duly assessed by a S-CAMHS clinical psychologist and placed on a waiting list.
On 15 May 2018, while she was waiting for treatment from S-CAMHS, Kianna attended the Accident and Emergency Department following an overdose of Tramadol. She told medical practitioners that she had intended to end her life. A referral was made to S-CAMHS and the local safeguarding board. The Council was also notified of her overdose. Consideration was given to Kianna being referred to the Child Care Assessment Team (“CCAT”).
On 17 May 2018 a meeting was held at Kianna's school. It was noted that she had been offered therapy with S-CAMHS and had access to the school counsellor and nurse. Ms Patton's evidence is that a social worker made an urgent referral for a Family Intervention Team (“FIT”) worker to be assigned to support Kianna, but that they were told the FIT did not have capacity to help them.
On 10 July 2018 a social worker assessed Kianna's needs but decided that the criteria for a care and support plan were not satisfied, because other services and her mother could meet her needs.
On 21 July 2018 Kianna was arrested for assaulting Ms Patton and taken to Haverfordwest Police Station. She refused to come home. A strategy discussion was held between the Council and the Police. It was eventually agreed that she would stay with a family friend until the relationship settled down.
Between 23 and 30 August 2018 a social worker assessed Kianna's needs, again concluding that she did not meet the criteria for a care and support plan as support from other agencies was available and was being provided through S-CAMHS.
Ms Patton and Kianna were offered ‘preventative’ support from the Team Around the Family (“TAF”) but they declined this. Ms Patton's evidence is that she had not found support from this team effective.
On 10 September 2018 a “contract” was signed by Kianna and her mother aimed at “setting boundaries and enhancing understanding of each other's wishes”. No child protection concerns were identified. On 14 September 2018 the CCAT “closed” Kianna's case, with her consent and that of her mother. On 1 October 2018 these steps were approved by a TAF manager.
On 14 June 2019 S-CAMHS discharged Kianna because she had been “feeling much better in herself since Dec 2018” and she had had “no more thoughts of harm to self or others”. She had stopped taking her fluoxetine (an antidepressant) as she reported that she no longer needed them.
Ms Patton was very concerned about Kianna's cannabis use and the effect that it was having on the other children in the home. As a result, on 23 June 2019, she asked Kianna to leave the family home. Kianna did so and moved in with a friend. However, Ms Patton was concerned that Kianna was being allowed to smoke cannabis at that home.
On 28 June 2019 Ms Patton contacted the Police to inform them that Kianna was staying at the home of a friend without her consent. She indicated to the Police that it was not suitable accommodation for Kianna because she was being allowed to smoke cannabis there. The Police re-directed her to the Council on the basis that they have statutory powers to provide accommodation. The Police log records that the information Ms Patton had provided would be shared with the Council. However, although a Multi-Agency Referral Form (“MARF”) was completed by the Police on 29 June 2019 and sent to a group local authority email address, the Council has no record of receiving it. It did not make its way on to Kianna's file.
On 29 June 2019 according to Ms Patton, she contacted the Council herself and provided the same information. Her evidence is that the Council told her that as her concerns involved recreational drug use, this was a matter for the Police. The Council has no record of this contact.
On 2 September 2019 Kianna visited her GP and stated that she was worried about schizophrenia and delusions (that her mother had killed herself and that she had been raped). She was hearing voices in her head. She was taking fluoxetine again. The following day, her GP made a further referral to S-CAMHS.
On 4 September 2019 Ms Patton submitted a written complaint to Stephen Crabb MP about the failure of the Council and the Police to help her with Kianna.
On 16 September 2019 Mr Crabb MP forwarded Ms Patton's correspondence to the Council. He asked the Council and the Police to agree a coordinated approach.
On 17 September 2019 S-CAMHS carried out an initial assessment of Kianna. She was assessed as posing low apparent risk to herself. Ongoing assessment was required with the Early Intervention in Psychosis Service (“EIPS”).
On 23 September 2019 Ms Patton contacted the Council and again raised the issue of Kianna being allowed to smoke cannabis at the house where she was living, her mental health issues and the fact that she had taken an overdose in May 2018. The social worker advised Ms Patton to remain in contact with Kianna by sending text messages and recorded that Kianna's college youth worker would offer supported lodgings or foster care if Kianna had any concerns in relation to accommodation.
On 24 September 2019 the Director of Social Services responded to Mr Crabb MP...
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