AN investigation into the death of a 17-year-old who died at a secure children’s home in County Durham has concluded her death could have been foreseen and “possibly prevented”.
The review was carried out by the Prisons and Probation Ombudsman into the death of Taylor Alice Williams, who was the first child in more than 20 years to take her own life in a secure children’s home.
Taylor, who had a history of self-harming and attempted suicide, died at Aycliffe Secure Centre, in Newton Aycliffe, on February 18, 2017.
The PPO report, which was written in April 2018 and refers to Taylor as “Child T”, was published following an inquest into her death.
On Thursday, a jury recorded that Taylor, who had been living at the centre since July 2016, had died by suicide.
Elizabeth Moody, who was acting PPO at the time, said: “It is clear that Aycliffe have a caring and motivated staff team. However, we identified a number of significant concerns about the way Child T’s risk was managed and about the effectiveness of well-being checks.”
She added: “Unfortunately, I think Child T’s death could have been foreseen and, possibly, prevented.
“Aycliffe need to introduce a more comprehensive, multi-disciplinary suicide and self-harm assessment and management system for those young people judged to be at risk to themselves.”
Ms Moody said suicide and self-harm measures lacked a detailed risk assessment process and described well-being checks as "inadequate".
On the day Taylor died she was being checked every five minutes.
But the PPO report described the checks as "superficial", some lasting only a few seconds.
It also found there was insufficient joint working between Aycliffe staff and the centre's forensic mental health team, which is provided by Northumberland, Tyne and Wear NHS Foundation Trust.
As well as the PPO investigation, there has been another by Ofsted and a serious case review.
As a result nine recommendations were made and have been and implemented.
Coroner Tanyka Rawden concluded she did not need to make a further report to prevent future deaths.
Aycliffe, which is the largest secure children's home in the country, has been sharing lessons learned from Taylor's death with other centres during the last 12 months.
Speaking at the end of the inquest, Margaret Whellans, corporate director of children's services at Durham County Council said the authority was leading a multi-agency working group to devise an action plan in response to the recommendations, resulting in a number of changes to policies and procedures.
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