Lessons have been learnt, says social care boss after St Annes teen's death
A Lancashire social care boss said lessons had been learned after a vulnerable teenager with serious mental health problems took his own life.
An inquest heard that when he was discharged from an in-patient psychiatric unit on January 6 2020, there was no social care provision already in place as his case had been closed two months earlier.
This had consequences further down the line.
While Marshall, of Heeley Road, St Annes, had been diagnosed with schizophrenia and needed to have his antipsychotic drug treatment carefully monitored, his mother was also suffering from episodes of hallucinatory psychosis.
But despite some concerns being raised about her ability to care for him, he went back to live with her.
Four months after leaving The Cove unit, Marshall took his own life in May 2020, and tragically his grief-stricken mother died at the family home just one month later, after taking a high dose of methadone.
The inquest into both their deaths is looking at whether opportunities to help them were missed.
Brendan Lee, head of service for children and social care at Lancashire, was asked why social care had been withdrawn in October 2019.
He said that Marshall's home visits from The Cove had stopped and said: " We looked whether there was a role for the children's and social care at that point, whether we were bringing about change. Had it run its course?"
The inquest heard that The Cove had expected the social care team to be in place upon Marshall's discharge.
Mr Lee conceded that a letter called a Section 85 Act letter from the Cove about Marshall being discharged should have triggered further action by the Children and Social Services.
It reached business support, not social services, and was not passed on - leading to delays in Marshall receiving social care support.
Mr Lee said: "The letter wasn't acted on, it was just seen as a letter."
He said a lesson learned was that such a letter should have been forwarded to social services and other departments had been told to now do so, while a qualified social worker is now expected to be on duty to respond to any letters.
Mr Lee was also asked about the option of alternative home placement for Marshall.
A leading psychiatrist at The Cove had said that no suitable accommodation existed to take in Marshall as a temporary alternative from his mother’s care.
Asked about whether he agreed that such accommodation could not be found if needed, Mr Lee said that some accommodation might have been found for him, as there were some provision available of Care Quality Provision standard.
He said: “Whether or not they would have met Marshall’s needs, I don’t know, but we do have four places looking after six young people.
“I’m not sure how Marshall would have engaged with carers, he was one of the most complex young men I have ever seen.”
Later in his evidence, he said it may have led to an application before a court if Marshall and his mother did not consent.
However, no such plans were pursued.
The inquest, led by coroner Alan Wilson, continues.