Children 'at risk' in Leicester home where teen died, coroner says

An inquest was held into 16-year-old Ash Bannister's death at Leicester's Town Hall

A coroner has raised concerns about a care firm after staff failed to check on a vulnerable teenager in the hours before their death.

Ash Bannister, 16, was found hanged in 2021 at The Laurels, run by United Children's Services, in Leicester.

Ash had a care plan that said they should be checked every morning, but this did not happen on 7 August 2021.

Coroner Isobel Thistlethwaite has issued a prevention of future deaths report, citing issues over Ash's care.

An inquest into the death of Ash, who identified as gender neutral, was held in Leicester and finished in April.

Ms Thistlethwaite, who gave a conclusion of suicide, issued the report - published on 30 April - to United Children's Services.

The coroner said more than two years after Ash's death, children "remain at risk".

In response, United Children's Services said it was "privileged to know" Ash, and would be responding to the coroner "shortly".

In the report, Ms Thistlethwaite said Ash, born in Croydon, south London, in 2004, had a difficult start in life and was known to social services in 2005.

'Conflicting evidence'

Ash was placed in foster care "due to concerns about neglect and the misuse of drugs at home", and eventually, in 2018, was moved into a residential placement.

The coroner said: "Ash had multiple vulnerabilities including early neglect, a difficult childhood, the fact Ash was a looked after child, a history of exposure to child sexual exploitation, mental health difficulties and a diagnosis of autism spectrum disorder along with some potential difficulties around eating and exploration of their gender identity."

Ash was under the care of Croydon Council, which moved them into The Laurels.

At the time of their death, Ash's support plan stipulated that they were to be checked every day at 07:00, but no checks were made on 7 August 2021, when Ash was found dead, the coroner said.

No reason was documented as to why staff deviated from the plan, and care home workers told the coroner they "would not expect to check on a teenager at 7am at the weekend in a normal family home".

In response, the coroner said The Laurels was "not a normal family home".

Ms Thistlethwaite said Ash had consumed alcohol on 5 August.

Due to "appropriate concerns about the consumption of alcohol when on anti-psychotic medication", staff put in an "ad-hoc waking night process", which meant a member of staff stayed outside their bedroom, awake, all night.

Staff described Ash as having a "good day" the following day, and no night cover was implemented, so Ash was not checked on from the time they went to bed at 21:50 on 6 August, to 09:00 the next morning, when they were found dead.

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Ash had also been subject to a ligature risk assessment from December 2020, with the risk brought down from "medium" to "low" in April 2021.

Between that time and Ash's death, the assessment was removed with no documentation as to when or why.

The coroner considered this lack of documentation a "grave concern", and also raised issues with the firm's policies, processes and training.

Ms Thistlethwaite said she heard "conflicting evidence" as to whether or not an investigation was undertaken by United Children's Services following Ash's death.

Two years and eight months after Ash's death, the coroner was told by the firm that it wanted to get the inquest process "out of the way" first before any changes were made.

She said: "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.

"It was accepted by United Children's Services that their investigation policy and process was not fit for purpose because it failed to identify all of the learning arising from Ash's death."

Ash was originally under the care of Croydon Council

The coroner added "the children in the care of the United Children's Services will, in my opinion, remain at risk" until changes were made.

The company has until June to respond to the coroner, and said it would be doing so shortly.

A spokesperson for the firm said: "Ash Bannister was a much-loved young person who we were privileged to know.

"The staff caring for Ash share Ash's family's deep shock and sadness at Ash's death.

"The coroner has raised a number of points for the organisation to consider and we are grateful for the opportunity to address these."

Croydon Council, which received a copy of the report, said it would "reflect" on the coroner's findings and that its "deepest sympathies are with Ash's family".

A council spokesperson said: "The council and our partners are committed to caring for our most vulnerable children and supporting young people experiencing mental health crises."