Kesia Leatherbarrow

On the 5th December 2013 commenced an investigation the death of Kesia Lena Mary Leatherbarrow aged 17 years_ The investigation concluded at the end of the Inquest on the 6th February 2015. The Conclusion recorded was a narrative conclusion indicating that; on the 3rd December 2013 at Ithe deceased died as a result of tying ligature around her neck There is not sufficient evidence to indicate that she was intending to end her life. The deceased had moved to the Manchester area on the October 2013 since when she had interactions with a number of agencies. There had been missed opportunities for agencies to obtain and collate information, to carry out adequate assessments of the information held and to consider appropriate levels of support: Despite these failings there is not the evidence to say on the balance of probabilities that any of these matters caused or contributed to her death:

do not propose to detail the significant evidence that was heard in this case save to say that the brief circumstances were as follows: The deceased had always resided with her family in the Lancashire area There had been increasing concern about her behaviour including her use , her abusive and aggressive outbursts, self-harming and her mental health: She had spent a month in July 2013 in the Platform facility in Preston, Lancashire: This is a mental health facility for young people. Upon her discharge matters deteriorated and on the 25th October Kesia was arrested by Lancashire Police. Her behaviour whilst in custody was concerning but she was not deemed to require sectioning under the Mental Health Act Following her release from custody on the 26th October she threatened to jump from a bridge: The same day she went to live with her Father in the Tameside area of Manchester. Kesia had had Iittle contact with her Father and he was not aware of all the recent issues and concerns surrounding Kesia. into 26th they drug

From this point onwards Kesia had Iittle contact with her mother and step-father who understandably had been severely impacted by the difficulties had faced with Kesia_ Due to concerns about her behaviour whilst she was in police custody in Lancashire, Lancashire Constabulary raised safeguarding report to the Multi-Agency Safeguarding Hub (MASH) which led to a referral to Lancashire Children's Services. This referral indicated that Kesia was high risk and likely to self-harm. Given that Kesia was now residing in the Tameside Area the referral was then forwarded by Lancashire Children's Services to Tameside Children's Services Upon receiving the referral only part of the information provided by Lancashire was then cut and pasted onto Tameside's own Referral Form which was inputted onto the computer system: There was therefore incomplete information on their own form although the Lancashire form was also scanned onto the Tameside Computer system When the case was reviewed not all of the information was considered as only the incomplete Tameside form was ever read. A decision was taken not to open a file and conduct a social work assessment for Kesia but to send referral to the Child Adolescent and Mental Health Service (CAMHS): Upon receipt of this referral Pennine NHS Foundation Trust assessed the information provided by Tameside and sent the referral to the administrator of the service for an appointment to be sent to Kesia. No appointment had been sent to Kesia at the time of her death: As a result of her arrest in Lancashire, Kesia was before the Magistrates Court in Preston on the 5th November 2013. She received referral order, Lancashire Youth Offending Team attended court and noted Kesia's new address in Tameside_ However the case which was then considered by at least people in Lancashire Youth Offending Team, was not transferred over to the Tameside Youth Offending Team at all prior to Kesia's death. On four occasions there was a failure to notice the new address for Kesia which was clearly marked on the documentation on the file. This meant that the referral order assessment and panel process was not commenced and concluded within the national guidelines prior to her death. There was also inappropriate thought given to breaching Kesia for non-compliance of her referral order. From the 28th October 2013 (whilst in the Manchester area) Kesia_ on at least 8 occasions prior to her arrest on the 30th November; had some interaction with officers from Greater Manchester Police. On one_occasion she_was_reported as missing_from home_bY_her Father; she they the was located the following residing with her boyfriend at the Armadale Road address_ On two occasions Kesia made calls to police with allegations of domestic violence against her by her boyfriend On another occasion she made report of an assault against by the ex-partner of her boyfriend On the November Kesia attended at her Mother's home in Lancashire where she was aggressive, threatened to push her grandmother down the stairs and had hold of a knife whilst threatening to self-harm. Officers from Lancashire Constabulary attended Kesia was calm at the time of their arrival and she was taken back to her Father's house by her Grandmother; Her Father was not provided with information as to the exact nature of what had occurred_ Lancashire Constabulary made further referral to their

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action;