Teen's care should have been escalated - inquest

Finn Hall, from Keighley, took his own life in November 2022 aged 16

A 16-year-old by who took his own life should have received additional support in the days before his death, an inquest has heard.

Finn Hall was found dead at his home in Keighley on 18 November 2022.

His family said they had asked Bradford District Care NHS Foundation Trust for additional help, stating he had made several previous attempts to kill himself

Giving evidence, patient safety adviser Christopher Hardy, who investigated the case, told the inquest there should have been "an escalation of the care being provided".

The hearing had previously been told that Finn had experienced problems with his mental health since the age of 11.

Earlier, the inquest heard that there had been an increase in his "risk presentation" in the 10 days before his death, which should have prompted a reassessment of his case.

Bradford Coroner's Court head how on 8 November, his sister had called his key worker at the Child and Adolescent Mental Health Services (CAMHS) to tell them he was talking about killing himself before or after Christmas.

Then, on 16 November, the family left a voicemail raising further concerns, but it was not responded to.

When Finn failed to attend an appointment with CAMHS the same day it did not lead to a reassessment of his case or escalation in care, the inquest heard.

Mr Hardy said, following his review of Finn's case, he had identified "a number of risk factors over weeks and months that didn’t result in escalation".

“Particularly from the 8 November onwards, but also in the weeks before that, there was an escalation in his risk presentation that was not reflected in his risk provision”, he said.

“There should have been an escalation of the care being provided.”

Finn's mum Hannah does not believe enough was done to help her son

Mr Hardy said one option would have been to discuss Finn’s situation at a multi-disciplinary team meeting to see if more intense support could be provided.

However, he added that because a reassessment did not take place it was difficult to know what that care could have looked like.

The Trust’s head of operations, Sadie Booker, gave her "full assurance” that action had been taken to address all the recommendations in Mr Hardy's report, including suggestions for more staff training, and that processes were regularly reviewed.

The coroner is expected to record their conclusion on Finn's death on 8 August.

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