Multiple state agencies missed safeguarding opportunities before Rhianan Rudd’s death, Chief Coroner finds
11 June 2025
Rhianan Rudd’s inquest was heard by the Chief Coroner of England and Wales at Chesterfield Coroner’s Court. Credit: Richard Coomber / Shutterstock.
On Monday (9 June 2025), an inquest into the death of 16-year-old Rhianan Rudd found that there were several missed opportunities by Counter Terrorism Police, Prevent, Derbyshire County Council and a number of mental health bodies in the period leading up to her death.
Rhianan, a highly vulnerable child, was the youngest female ever to be charged with terror offences in the UK. The prosecution was discontinued when Rhianan was eventually recognised as a victim of modern slavery due to the online exploitation she had suffered. Her death was the result of a self-inflicted act at a children’s home in May 2022.
Garden Court North’s Ciara Bartlam and Matrix Chambers’ Jesse Nicholls represented Rhianan’s mother at the 16-day inquest, held at Chesterfield Coroner’s Court.
Findings by the Chief Coroner
The inquest was heard by the Chief Coroner of England and Wales, Her Honour Judge Alexia Durran, whose findings included:
1) A potential systemic failure by Counter Terrorism Police and Derbyshire County Council to refer Rhianan to the National Referral Mechanism, the body responsible for identifying potential victims of modern slavery, at an earlier date.
2) A failure by Derbyshire County Council to refer Rhianan for mental health support at an earlier stage and to arrange long-term therapeutic support for Rhianan.
3) A failure to provide Rhianan with the direct mental health support she required from Nottinghamshire Child and Adolescent Mental Health Services (‘CAMHS’). This lack of input left Rhianan without any input from mental health services from May 2021 until her death in May 2022.
4) Forensic CAMHS (‘FCAMHS’), a body responsible for the mental health care of young people in the criminal justice system, had no positive impact in Rhianan’s case. FCAMHS did not provide a plan for her care or help to coordinate multi-agency support. The involvement of FCAMHS may even have had a detrimental impact by masking the fact that there were no professionals working directly with Rhianan.
5) Officers from Prevent did not consider the impact of their intervention on Rhianan, the focus of the intervention was changed shortly before Rhianan’s death without discussion with relevant professionals, and this change in focus was inappropriate.
Emily Carter, Rhianan’s mother, said: “My beautiful daughter Rhianan was loving, kind-hearted and clever. She loved nothing more than to laugh and brought so much joy to our family and those around her.
“Losing Rhianan as we did was the most painful and traumatic experience any family could have to go through. To hear at her inquest today that she was let down by the police, the Prevent anti-terror programme, Derbyshire County Council and the mental health bodies only increases our anguish.
“Rhianan’s young age, autism and other vulnerabilities made her an easy target for those who sought to groom and exploit her for their own ends. These people filled her head with ideas that were not her own and caused her to act in ways which would never otherwise have occurred to her.
“After I raised concerns about her behaviour to the authorities, instead of being treated as a highly vulnerable victim of exploitation, Rhianan was treated as a terror suspect and a criminal.
“The Chief Coroner has found that Rhianan was denied access to services which should have supported and protected her and, I believe, could have saved her life. Looking at the number of missed opportunities recognised by the coroner, it’s hard to see how they cannot have had an impact on Rhianan’s state of mind.
“I believe there were many people in positions of authority who could and should have realised mistakes were being made in the way Rhianan was treated and that opportunities to support her were being missed. Throughout this time, I saw first-hand the impact these failings had on my daughter’s mental health in the period before she took her life.
“Whilst nothing can ever bring Rhianan back, I urge all the authorities that came into contact with her to learn from what happened so that no other family has to experience the pain we have endured. If this truly happens, my hope is that positive change can come from this tragedy and can be a lasting legacy to my beautiful daughter Rhianan, who I will always love and cherish.”
Anna Moore, the family’s solicitor and Partner at Leigh Day, said: “It is significant that the coroner has recognised there were a number of missed opportunities by several of the agencies which came into contact with Rhianan before her death, including Counter Terrorism Police, Prevent, Derbyshire County Council and a number of the mental bodies.
“Rhianan was described by some of those involved with her as the most vulnerable child they had ever come across; many of the agencies which dealt with her over a period of many months had legal obligations to safeguard her, and yet she was still let down.
“When Rhianan’s mother turned to the Prevent programme for help, she had no idea this is how things would end. Instead of being treated as a victim of grooming and exploitation Rhianan was criminalised. This in turn meant she was removed from her family home and further failings meant she was denied the specialist mental health support she so desperately needed.
“This has been an exceptionally gruelling process for Rhianan’s family, who want to ensure that children who are victims of online grooming and exploitation are recognised as such and given the appropriate support, rather than being dragged through the criminal process.
“The findings today confirm that the key protections for a vulnerable child were denied to Rhianan.” I sincerely hope lessons are learnt by all those involved so that no other family has to endure the trauma of losing a loved one in this way.”
Ciara was led by Jesse Nicholls of Matrix and instructed by Anna Moore, Partner at Leigh Day.
Additional media
Matrix Chambers – Rhianan Rudd Inquest identifies multiple missed opportunities by State agencies
BBC – ‘Chances missed’ to help groomed terrorism suspect
The Guardian – UK teenager who killed herself was ‘highly affected’ by terrorism arrest, inquest finds
For further information, please contact Alex Blair, Communications Manager at Garden Court North Chambers: ablair@gcnchambers.co.uk
