Liam Hardy

On the 13th June 2014 concluded an Inquest into the death of Liam Hardy, a 15 year old schoolboy: The medical cause of death was hanging, and recorded a narrative conclusion as follows: At about 9 pm on 19"h November 2012 at his grandfather's home (address redacted) .Liam became upset and agitated while exchanging text messages. He tied his school tie around his neck and attached the other end to the upper part of a bunk bed He sat 0n the lower bunk and the ligature caused him to lose consciousness. On the balance of probability he did not intend to die. His actions were in part because his complex behavioural and emotional problems were not adequately or appropriately assessed or managed by social and mental healthcare services, and the risk to his life by acts of self harm was not recognised or adequately managed. There were failures to fully share or access information, and significant events were dealt with in a timely fashion or at all. The services placed too much reliance on addressing his needs through the family therapy service who failed to acknowledge that their intervention was not effective in addressing Liam needs. Other agencies did not appreciate the role and limitations of the family therapy service with the consequence that alternative andlor additional measures to protect Liam were not fully explored or considered

Please see the conclusion set out in paragraph 3. Further information can be provided if required

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

At about 9 pm on 19"h November 2012 at his grandfather's home (address redacted) .Liam became upset and agitated while exchanging text messages. He tied his school tie around his neck and attached the other end to the upper part of a bunk bed He sat 0n the lower bunk and the ligature caused him to lose consciousness. On the balance of probability he did not intend to die. His actions were in part because his complex behavioural and emotional problems were not adequately or appropriately assessed or managed by social and mental healthcare services, and the risk to his life by acts of self harm was not recognised or adequately managed. There were failures to fully share or access information, and significant events were dealt with in a timely fashion or at all. The services placed too much reliance on addressing his needs through the family therapy service who failed to acknowledge that their intervention was not effective in addressing Liam needs. Other agencies did not appreciate the role and limitations of the family therapy service with the consequence that alternative andlor additional measures to protect Liam were not fully explored or considered