THE INQUEST into the death of 14 year-old Derek Brundrett, who was found hanged at Pembroke School in December 2013, has found that there were individual failings in efforts to get psychiatric support for the teenage boy – who then went on to take his own life.
Derek had seven different social workers and record keeping by social services was in a “shocking state of affairs” leading up to his death.
Returning a narrative verdict, the Assistant Coroner, Paul Bennett, said: “That Derek Brundrett took his own life and intended to do so in circumstances where, despite efforts to refer him for psychiatric support there was a failure to do so.”
Although no systemic failures were found, the Assistant Coroner ruled that there was a failure to refer by a social worker, a failure by a GP to provide extra information when referrals in 2012 and 2013 were declined, and a further failure to provide the relevant information on the appropriate referral form of a Looked After Child.
Derek’s death was in the context that he had been returned to foster care and was concerned about a return to the Pupil Referral Unit.
Derek’s actions were not considered to be a cry for help but rather a deliberate attempt at self-harm, the Coroner’s report stated.
The inquest had previously heard there were numerous failed attempts to refer him to mental health services.
A social services referral plan was not completed by Derek’s social worker because “she believed him to be happy”.
The inquest also heard Derek’s GP had made “routine” referrals for mental health treatment in 2012 and 2013.
Angela Lodwick, head of the Child and Adolescent Mental Health Services (CAMHS) for the Hywel Dda University Health Board, said they had to “prioritise children with severe mental health disorders”.
She added requests for more information about Derek’s condition went unanswered.
But she told the inquest that, at the time, CAMHS was not proactive in seeking more information.
Ms Lodwick said CAMHS would have probably “taken him on referral and made an assessment” if they had known about Derek’s risk-taking behaviour and talk of suicide in 2013, such as when he climbed onto the school roof.
She told the inquest the system had been inadequate and “the position was that everyone sat on their hands waiting” but CAMHS has since made improvements.
A spokesman for the Pembrokeshire County Council said: “The death of a child is a profound loss and all the professionals involved in this tragedy feel great sympathy for Derek and his family and friends. We would like to repeat our sincere condolences to them at this time.
“Derek’s loss is deeply felt by those individuals who had formed close and caring relationships with him.
“We would like to thank the Coroner for his thorough investigation and consideration of the case.
“We will, of course, reflect upon all of the issues that have been raised during the Inquest, and consider what lessons can be learned with a view to continuing to ensure the safeguarding and well-being of all children and young persons served by Pembrokeshire County Council.”
