The death of a teenage girl who tragically took her own life was “unavoidable”, a coroner has today ruled.
Coroner Guy Davies has said the death of 16-year-old Beatrix Hart, known as Trixie, could not have been prevented, despite the “heroic” efforts of those around her.
Mr Davies made the comments following a three-day inquest in Cornwall which yesterday heard Trixie had claimed to have been a victim of grooming and sexual assault before she took her own life at her home in Gunnislake, Cornwall.
But today the court was told her death on Thursday, September 20, 2018, was “unavoidable” with the coroner praising the efforts of her parents, grandparents and the “dedication of the mental health professionals”.
Leading up to her tragic death, Trixie lived in Cornwall and Southampton.
Mr Davies said: “We’ve heard that she was an intelligent and engaging child with an exceptional talent for music and singing, she felt things deeply and had a strong sense of justice.
“Her mother Charlotte Ballinger described her as complex, and one witness in discussion with Ms Ballinger, a teacher, described her as the most complex child he had ever met.
“Ms Ballinger said this about Trixie, that she was bright, gifted, kind, also deeply sensitive and emotional and struggled to regulate this.
“It often overwhelmed her to the point she would become angry and destructive.”
He said discussions had taken place about whether Trixie had ADHD and she was diagnosed with anxiety and depression, and unstable emerging personality traits in the last few months of her life.
He said: “I know during her long struggle with mental health issues she had multiple admissions to Derriford Hospital in Plymouth, and hospitals in Southampton with a number of intentional overdoses.”
Where to get support for mental health
There are dozens of places to get online help, including web-chats, text help, phone-calls and even apps with games to help you manage your feelings.
If you are needing help or just want to know what is available to you, we have compiled a full list of a number of services here.
Below are just some of the helplines and websites that can help you.
Samaritans (116 123) operates a 24-hour service available every day of the year. If you prefer to write down how you’re feeling, or if you’re worried about being overheard on the phone, you can email Samaritans at email@example.com.
Pete’s Dragons (01395 277780) provides specialist support and advice for those affected by suicide in any way via telephone or email at firstname.lastname@example.org.
Childline (0800 1111) runs a helpline for children and young people in the UK. Calls are free and the number won’t show up on your phone bill.
PAPYRUS (0800 068 41 41) is a voluntary organisation which speaks openly about suicide and supports teenagers and young adults who have may suicidal thoughts. You can also get in contact with Papyrus via text on 07786 209697 or email via email@example.com.
The opening hours are as follows; 9am – 10pm weekdays, 2pm – 10pm weekends, 2pm – 10pm bank holidays.
Depression Alliance is a charity for people with depression. It doesn’t have a helpline, but offers a wide range of useful resources and links to other relevant information. http://www.depressionalliance.org/
Students Against Depression is a website for students who are depressed, have a low mood or are having suicidal thoughts. Bullying UK is a website for both children and adults affected by bullying. http://studentsagainstdepression.org/
The Sanctuary (0300 003 7029) operates a 24-hour service available every day of the year, for people who are struggling to cope – experiencing depression, anxiety, panic attacks or in crisis.
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Livewell Southwest provides integrated health and social care services for people across Plymouth and other parts of the region. For anxiety and depression enquiries please email email@example.com.
SHOUT (85258) is a 24/7 UK crisis text service available for times when people feel they need immediate support.
By texting ‘SHOUT’ to ‘85258’ a Texter will be put in touch with a trained Crisis Volunteer (CV) who will chat to them using trained techniques via text. To get help or find out more about how Shout works, visit the Get Help page.
Trixie had also been the victim of alleged grooming and sexual abuse in the past.
Mr Davies concluded that Trixie died at her home in Cornwall as a result of suicide.
Toxicology revealed that Trixie had consumed alcohol and there was evidence of cannabis use.
He said: “In the context of Trixie’s mental illness and expressed intention, her death was almost inevitable, there were failings by social services, children’s services that is, and Duchy College, but there’s insufficient evidence that had these failings been avoided her life would have been saved.”
He added: “Trixie’s death was due to her being overwhelmed by her mental health issues, there was nothing more the family could have done, there was nothing more that mental health services could have done to prevent this terrible outcome.
“Trixie’s death in that sense was unavoidable notwithstanding the heroic efforts of parents, grandparents and wider family and the dedication of the mental health professionals.”
Mr Davies explained how Trixie and her family engaged with support services and how they had been failed by them.
He started with Cornwall Council children’s services.
Following alleged sexual abuse Trixie had been placed on a child protection plan.
Women’s Refuge Cornwall
Rape & Sexual Abuse Helpline & Domestic Abuse Helpline: 01208 77099
For immediate out-of-hours support
Rape Crisis: 0808 8029999
Women’s Aid: 0808 2000247
In March 2017 a child protection conference recommended the discontinuance of that plan, and it was recommended Trixie be the subject of a ‘child in need’ plan.”
According to Rebecca Sargent of Cornwall Council Children’s Services there are three types of plans, most serious is a child protection plan, then it’s a child in need plan, and finally an early help plan.
Mr Davies said the chairman of the conference unilaterally decided not to implement the recommendation and instead decided to pursue support through an early help plan.
He said “This was without consulting other members of the child protection plan conference and in breach of recognised practice and procedures.
“The early help support was then not delivered due to a mistake by social services. The effect of that was to leave Trixie and her family without any support from children’s services.”
The evidence was that a child in need plan was required but wasn’t delivered.
Mr Davies added: “The court heard evidence of the impact that there was no support for the family by children’s services for that period of March to June 2017, no meaningful support, that culminated in Trixie taking an overdose in June 2017.”
He called it a “total and complete failure”. Changes have since been implemented.
After that incident Trixie moved to Southampton to be with her dad.
Mr Davies then went on to discuss the failures by Southampton children’s services.
Do you need someone to talk to?
There are a range of local and national organisations which can provide emotional support over the telephone or internet.
The Samaritans – 116 123
You can contact The Samaritans who are available 24 hours a day 365 days a year by phone as well as by email, text and post.
Telephone: Free of charge from landline or mobile: 116 123
Nightlink – 0808 800 0306
Nightlink is an emotional support helpline and text service for anyone in Cornwall who is experiencing emotional distress. All calls are confidential. Nightlink is available 7 days a week from 5pm – midnight
Text service 07717 989 021
*SANE – 0845 767 8000
SANE offers support to anyone coping with mental illness, including concerned relatives or friends.
The SANE helpline is available 7 days a week from 6pm – 11pm.
Papyrus are the national UK charity dedicated to the prevention of young suicide and they provide:
HOPElineUK – 0800 068 4141
This is a specialist telephone helpline for children, teenagers and young people up to the age of 35. Call Hopeline if you have concerns about suicide either for yourself or for someone else. Alternatively visit their website at https://www.papyrus-uk.org
Text: 07786 209 697
CALM – 0800 58 58 58
Specifically for men, this service is open 7 days a week, from 5pm to midnight.
STAY ALIVE APP
The Stay Alive app is a pocket suicide prevention resource for the UK, packed full of useful information and tools to help you stay safe in crisis.
ANDY’S MAN CLUB
Andy’s Man Club has four groups across Devon (Plymouth, Newton Abbot, Torbay, Exeter). It provides men with a safe, non-judgemental, confidential place to get stuff off their chests.
Trixie and her family were let down during the time she was in and out of hospital after a mental health episode.
Mr Davies said: “The evidence points that the children’s services did not meaningfully engage with the family or offer support to the family during that period.”
He said they failed to attend a number of meetings, including a discussion of discharging Trixie from the hospital.
He added that Trixie was discharged back to the family without any meaningful support.
Mr Davies called it a ‘gross failure’ by Southampton children’s services. Changes have since been implemented.
Mr Davies then turned to Solent NHS. He said there was no interruption to mental health care whilst Trixie was under the care of Solent NHS during her time in Southampton and Hampshire.
He said appropriate care was given as far as possible in the circumstances.
Mr Davies discussed the decision to admit Trixie to Leigh House psychiatric unit in Winchester after a mental health episode, and said it was unavoidable because Trixie claimed she would try to take her own life if she wasn’t admitted.
Solent staff at the time wanted to avoid that admission and said it could be damaging to Trixie and Mr Davies said her admission turned out to be counterproductive to her health.
He said it was the threats from Trixie that made the decision unavoidable.
He then discussed a psychiatric review on July 27, 2018 and the transfer to Cornwall.
There was a family therapy meeting on May 23, 2018, in which Trixie revealed her plan to return to Cornwall and on 27 July 2018 she expressed threats to end her life there.
Mr Davies said: “The risk of Trixie acting on these thoughts at the time were considered to be high, but there was no conversation between CAMHS Solent and Ms Ballinger, this is an omission but my finding is, it’s not a failure because the information shared with Mr Hart, Trixie’s father, who was asked to share the information with Trixie’s mum, which he did.
Mr Davies said lessons have been learned that frank and direct conversation between professionals and family members would benefit those involved in such situations.
Mr Davies then discussed the actions of Southern Health NHS which operates Leigh House the psychiatric hospital for young people.
Trixie was admitted to the hospital despite worries it might escalate damaging behaviour.
Mr Davies said: “This was a known risk but it was unavoidable due to the threats made by Trixie to harm herself if not admitted and I find there’s no alternative to admission.
“I accept the evidence of Dr Nixon (of Leigh House) that whilst care treatment in Leigh House was unable to prevent escalation in damaging behaviour there was no reasonable treatment to avoid such an outcome and all reasonable steps and treatment were taken in connection with her stay.
“The decision to discharge Trixie was in accordance with clinical judgement that damaging behaviour was escalating but also that there was no imminent and immediate risk that Trixie would take her own life.
“The risk was the other way round that Trixie would take her life if she wasn’t discharged.
“The problems and issues around discharging rather lie at the door of children’s services and the failure to support the family rather than with Southern Health.”
The inquest also highlighted failures by Duchy College.
Prior to her death, Trixie was enrolled at Duchy College on an animal welfare course. This followed a successful interview on August 31, 2018.
Ms Ballinger was adamant that both Trixie and herself would have discussed her daughter’s psychiatric history at length during the interview.
However, documentation by Duchy College was at odds with this.
Mr Davies said: I prefer the evidence of Ms Ballinger it’s not credible in the context of Trixie’s struggle with mental health problems that her psychiatric history would not be the subject of disclosure at that meeting and discussion.”
As a result of that meeting Trixie was placed into safeguarding tiers 2/3 when she should have been in tier 4.
Mr Davies said: “That being the case the evidence of the Duchy was that safeguarding measures should have been implemented namely deferring enrollment and seeking information from CAMHS and the multi-agency referral unit.”
There was also a safeguarding note provided to Duchy College on or around September 13, 2018 when Trixie made a reference to having attempted to harm herself in the past.
Mr Davies said: “Duchy College did not implement any safeguarding measures to that, they did not suspend enrollment or upgrade the risk category, they didn’t seek to obtain information from agencies regarding Trixie and her risk level.
“As a consequence she remained enrolled and when she didn’t attend college on September 20, 2018, the college didn’t ring Miss Ballinger to notify her.
“This was a gross failure by Duchy College to implement safeguarding measures. This was a total and complete failure.” Changes have since been implemented.
Yesterday, Ms Ballinger said: “That still stays with me (no text from the college) if I received a text that day (informing her Trixie missed college) she would still be here.
“We had a policy, my mum and I, that if I knew she wasn’t in college my mum would be here within minutes and it was a good couple of hours after she (Trixie) spoke to the college (in the morning) that she died.
“We would never have left her on her own.”
It was also revealed during yesterday’s inquest that the college didn’t involve any of Trixie’s family in their internal investigation into what happened.
Meanwhile, she wasn’t sent a condolence letter by the college.
She said: “Even after I lost Trixie this is the first time I have spoken to someone from Duchy College since she died.
“When she died there was an internal review and I wasn’t contacted at any point.
“I felt like the shutters came down at Duchy College and the family weren’t part of that conversation.”
She said she was aware a lot of different groups were talking to her at the time, and Duchy College was the only one which wasn’t.
She added: “I didn’t know or understand the reason for that and I was too scared and shocked at the time to process that.”
Giving evidence, Ms Ballinger said: “I think the really overarching pattern that we’ve experienced over the past few years with different agencies and different professionals is that they didn’t know what to do with her..
“There was often a sense of when things were difficult it was handed back to us and to take her away.
“There were a few moments where I felt and Chris (Trixie’s dad) felt too, completely abandoned, and we would ask for more help, even though it wasn’t going to help anymore, but we kept on persevering because she was our daughter and kept doing it, but it was hard going, and I’ve heard lots of evidence about professionals recognising mistakes have been made and there’s some relief in hearing that acknowledged and hopefully things can change for other people and their families.
“We desperately wanted to help her, I reached out for help so many times and generally what seems to happen is you end up feeling like you’re being blamed or not managing her properly and just lock her up, keep her in.”
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