She draws on her previous experiences in order to apply a rare and invaluable level of expertise and insight
Ciara Bartlam is a member of our Inquests and Inquiries team and specialises in representing bereaved families whose loved ones have died under the age of 25 in community and detention settings. Ciara aims to put the young person’s voice and interests at the centre of the inquest process and to understand who they were as thoroughly as she can.
Before becoming a barrister, Ciara worked in children’s services as a specialist homeless officer for 16 and 17 year olds and care leavers under the age of 25. As a result, Ciara has experience working with young people with complex and multiple needs – including histories of trauma, exploitation, and offending – which she regularly draws on in her work. She has also worked alongside a range of services, including community mental health teams and youth offending.
Ciara is keenly aware of the impact of austerity on the availability of services and demand for them. Her expertise in housing, mental health and social care law gives her a unique edge in complex inquests arising from deaths in the community, particularly those who have died in supported accommodation settings; like 16 year old Ben Nelson-Roux, who died in April 2020 while placed by North Yorkshire County Council in a homeless B&B which was recognised to be unsuitable for his needs.
Ciara has a particular concern about the number of queer and/or neurodiverse young people who die prematurely across a range of settings. Because this information is not captured on a death certificate, it is not possible to know with certainty how many young people are affected and the extent to which this problem has grown in recent years. Some examples of Ciara’s work include representing the families of Charlie Millers and Rowan Thompson, two of three young people who died between October 2020 and June 2021 while under the care of the Greater Manchester Mental Health NHS Foundation Trust; and the father of Max Sumner who died at the age of 17 following a catalogue of errors by his local Child and Adolescent Mental Health Service.
Ciara is ranked as a Tier 1 Rising Star for Inquests and Inquiries by The Legal 500 and in Band 3 in Chambers and Partners for the same area. In 2022, Ciara was awarded a Legal Aid Lawyer of the Year Award in the Legal Aid Newcomer category.
Outside of her work as a barrister, Ciara is a trustee at the Greater Manchester Law Centre, where she contributes to strategic planning, building the next generation of social welfare lawyers and community outreach.
Ciara's pronouns are she/her or they/them.
Ciara is ranked as a Tier 1 Rising Star in The Legal 500 and in Band 3 by Chambers and Partners. Some of her recent cases include:
Inquest into the death of Charlie Millers (April 2024): a three week inquest in front of HM Senior Coroner Joanne Kearsley sitting with a jury. Charlie was a 17 year old trans young person who died from self-inflicted injuries sustained at Junction 17, a CAMHS inpatient facility operated by Greater Manchester Mental Health NHS Foundation Trust. The jury found multiple failings in the care Charlie received from children’s services and GMMH and concluded that the decision not to place Charlie on 1:1 observations probably contributed to his death.
HM Senior Coroner Joanne Kearsley issued a prevention of future deaths report to the then Secretary of State for Health and Social Care outlining her concern that the deaths of patients detained under the Mental Health Act 1983 are not subject to the same level of independent investigation as deaths in police custody (Independent Office for Police Conduct) or in prison (Prison and Probation Ombudsman).
Charlie’s inquest was covered by national and regional news outlets, including the Guardian, Sky News and MEN.
Inquest into the death of Matthew Terrill (February-March 2024): a three week inquest in front of a jury, where the relevant officers and police force were represented by two King’s Counsel, one senior-junior barrister and two junior barristers. Matthew was a vulnerable adult who had a history of mental ill health and was physically disabled. He was found in a park in April 2020 having consumed an unknown quantity of illicit substances and was later restrained in police custody where he sadly died. The jury ‘concluded that there were fundamental failings in training, documentation and communication’ on the day of his death.
HM Assistant Coroner Alexandra Pountney issued a prevention of future deaths report directed at the Chief Constable of South Yorkshire Police outlining seven concerns about the training and documentation used by the force.
Inquest into the death of Max Sumner (January 2024): a non-Article 2 inquest in front of HM Area Coroner Kate Bisset. Max was a 17 year old trans young person who died by suicide in May 2022. The Coroner found that there were 13 failures in Max’s care and that his case ought to have been escalated to children’s safeguarding by March 2022 at the latest. She concluded that ‘had Max’s care been different, in particular had his confidentiality been breached in March 2022, along with escalation to children’s services and discussion of inpatient treatment, it is more likely than not that Max would not have died at the time at which he did because he would not have been afforded the physical opportunity.’
Inquest into the death of Ben Nelson-Roux (September 2022, concluded March 2023): a three week Article 2 inquest in front of HM Senior Coroner Jon Heath. Ben was 16 years old when he died in an adult homeless hostel. Ben was diagnosed with ADHD and was a victim of Child Criminal Exploitation. Although the accommodation was recognised to have been unsuitable for Ben’s needs, the Coroner was unable to say whether this contributed to Ben’s death because the medical cause of death could not be ascertained.
Due to concerns about the availability of suitable accommodation for teenagers like Ben, HM Senior Coroner Jon Heath issued a prevention of future deaths report directed at the relevant Local Authorities and the then Secretary of State for Health and Social Care. Ben’s inquest was covered by national and regional news outlets, such as the Mail Online and Newsnight.
Inquest into the death of Rowan Thompson (October 2022): a six day inquest in front of HM Senior Coroner Joanne Kearsley sitting with a jury. Rowan was 18 years old when they died from severe hypokalaemia at Junction 17; a CAMHS inpatient facility operated by Greater Manchester Mental Health NHS Foundation Trust. They were the first of three young people to die at Junction 17 between October 2020 and June 2021. The jury found that Rowan’s death was contributed to by neglect.
HM Senior Coroner Joanne Kearsley issued a prevention of future deaths report to GMMH and NHS England outlining her concerns about the efficacy of the system for auditing observations and documentation; the investigation following Rowan’s death; and the absence of a deputy or ward manager on the Gardener Unit over the weekend.
Inquest into the deaths of Marshall Metcalfe and Jane Ireland (November 2021): a two week inquest in front of HM Senior Coroner Alan Wilson assisted by Counsel to the Inquest. Marshall was a 17 year old young person and Jane’s son. Following an assault against Jane in 2010 and the death of Marshall’s father in 2016, Jane developed symptoms of psychosis and was admitted to an inpatient psychiatric unit for treatment. Less than a year later, Marshall was admitted to a CAMHS unit and spent most of the next year and a half of his life detained under section 3 of the Mental Health Act 1983. In January 2020, Marshall was discharged to Jane’s care without support from children’s services. Tragically, Marshall died by suicide in May 2020 and Jane died one month later.
Marshall and Jane’s inquests were joined following submissions from the family and reported here and here. After hearing evidence that a child or young person’s case will regularly close to children’s services when they are admitted to a psychiatric inpatient unit, the Coroner issued a prevention of future deaths report to the then Minister of State for Care and Mental Health.
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