Coroner's 'grave concerns' about company behind care home where child died

The inquest took place at City Hall in Leicester
The inquest took place at City Hall in Leicester -Credit:Google

A coroner has expressed "grave concerns" about a company which runs a care home for children in Leicester. It comes after an inquest concluded last week into the death of Ash Bannister, who was 16 when they took their own life at The Laurels care home, run by United Children's Services, in Groby Road, in the city.

Coroner Isobel Thistlethwaite has issued a Prevention of Future Death Report to United Children's Services highlighting issues raised about the company by the case - in particular, her belief that more young people in the company's care could die. She said in the report: "During the course of the investigation, my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken."

The report by Ms Thistlethwaite, assistant coroner for Leicester City and South Leicestershire, highlighted three main areas of concern: that Ash was removed from a risk assessment which identified them as being at risk of taking their own life; that Ash was not watched for several hours when they should have been regularly observed; and the company's "inadequate" investigations process.

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The inquest heard that Ash, who had complex needs and had been self-harming from the age of nine, had been made the subject of a Ligature Risk Assessment over fears they could try to take their own life. But at some point shortly before they died, in August 2021, that risk assessment was removed, with no documentation to say exactly when or why.

The court was also told that the morning after the night Ash died, they should have been checked on at 7am, but no check was carried out, in breach of the home's policy. Ash was unsupervised for 11 hours straight, despite having been on constant watch, known as waking night cover, the night before.

The coroner said in the report that she had "heard conflicting evidence" as to whether an investigation was undertaken by United Children’s Services after the death of Ash, who was gender neutral. The inquest heard evidence that there was no investigation at all, while one manager said there was an investigation, but the results were not documented.

Ms Thistlethwaite said: "I heard evidence to confirm that United Children’s Services do have an investigations policy, albeit that document was not disclosed to the court despite a request for confirmation as to whether any internal investigation of any kind was undertaken and confirmation of what investigatory processes were available to United Children’s Services to use after Ash’s death."

The coroner said a United Children’s Services board meeting took place in spring 2022 during which required changes to the company's policies were discussed - but there still had not been any actual changes. Ms Thistlethwaite said: "Two years and one month after the board meeting and two years and eight months after Ash’s death, those changes had 'not yet' been made.

"I asked why changes had not been made and was told that United Children’s Services wanted to get the inquest process 'out of the way' before making any changes. I have grave concerns about the fact that United Children’s Services have been running homes in the knowledge that they have an inadequate investigation process in place for over two years.

"I have concerns about policies and processes in place at United Children’s Services, including the investigations policy, the policies governing risk assessments, in particular the ligature risk assessment, and the ad hoc waking nights process. I heard evidence at the inquest about United Children’s Service’s plan to make what appear on the face of it to be broad and wide-reaching changes to their policies and processes.

"However, at the time of writing this report those changes have not been discussed, finalised, implemented or embedded. The children in the care of the United Children’s Services will, in my opinion, remain at risk until such time as appropriate and effective action is taken and the necessary changes are implemented and embedded at the company and within their care homes."

The company is now legally required to respond to the coroner within 56 days with details of what actions will be taken.

Anyone needing help with suicidal thoughts can call the Samaritans’ helpline on 116 123.