Prevention of Future Deaths Report to go to the Secretary of State for Health & Social Care following Charley Patterson Inquest

7 November 2022

The Senior Coroner for North and South Northumberland, Mr Andrew Heatherington, has issued a Prevention of Future Deaths report to the Health Secretary, in light of concerns arising from the inquest into the tragic death of Charley Patterson.

Charley was found unresponsive at her home in Cramlington, Northumberland, on October 1st, 2020. Charley had been bullied and struggled to get mental health support in the months before her death.

Northumberland Coroner’s Court heard how Charley told a nurse, after harming herself for the second time, that she had been bullied online. A plan was made to refer her to the Northumberland (Early Help) Hub but the referral was never processed by the trust. The inquest heard how it was then wrongly assumed that a referral had been made.

Following a four-day inquest, the Senior Coroner found that Charley suffered from low mood and anxiety related to a number of factors including bullying and the COVID lockdown. He also found that she had suffered from bullying in the period leading up to her death.

The Senior Coroner found that Charley attended hospital on 29 May 2020 after she had self-harmed for a second time. She was seen for cuts to her arm and told clinicians that she wanted support with her anxiety and low self-esteem and to learn positive coping strategies for times of emotional distress. The Coroner concluded that no referral had been made for Charley to the Northumberland (Early Help) Hub following her attendance at hospital and there was an absence of communication with other services and professionals.

The Prevention of Future Deaths report can be found here. The Report raises concerns in relation to evidence heard at the inquest that there has been an increase in the numbers of children and young people presenting with mental health difficulties and psychological distress since the COVID-19 pandemic, and the delays that now exist before they receive treatment and support.

The Senior Coroner has called on the Secretary of State to assess the services and resources that can be offered to meet this increase in demand for mental health care and to reduce delays in receiving early support in order to avoid a mental health crisis.

Charley’s family is campaigning for ‘Charley’s Law’, which calls for improvements in mental health provision for young people. They want to see all first appointments with children’s mental health services take place within a month of referral; weekly support meetings and more regular meetings with all key players in a child’s life, including doctors, parents, teachers, and social services.

The family have also called on schools to educate children at a younger age about bullying and safety online.

The inquest has been heavily reported in the media:

Charley’s parents, Jamie and Paul, were represented at the inquest by Lily Lewis of our Inquests & Inquiries team. Lily was instructed by Abigail Gowland of Watson Woodhouse solicitors.

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