Serious failings by corporate parent and other agencies contributed to Nonita Grabovskyte’s death, inquest finds
27 May 2025
Garden Court North’s Ciara Bartlam represented INQUEST and Article 39 pro bono in Nonita’s inquest at North London Coroner’s Court (pictured). Credit: Richard Kelly / Creative Commons.
An inquest has found that a severe absence of co-ordinated arrangements for an “extremely vulnerable” child in care approaching her 18th birthday contributed to her self-inflicted death. Nonita Grabovskyte died after being struck by a train on 28 December 2023, just two weeks after turning 18.
Nonita was autistic and had a history of mental ill health, disordered eating, self-harm and hospitalisation. She told professionals that she had been sexually abused in early childhood.
The inquest heard that Nonita was very creative, making artwork and bracelets and recently selling items online. She loved Hello Kitty, My Little Pony and watching Disney movies. She was academically able, having achieved six good GCSEs. Nonita adored animals and was thinking about becoming a vet.
Garden Court North’s Ciara Bartlam represented INQUEST and Article 39 pro bono, instructed by Serena Fasso and Blodina Rakovica of Wilsons Solicitors LLP.
Nonita’s backstory
The London Borough of Barnet (LBB) had been Nonita’s ‘corporate parent’ since May 2022, when she was 16 and after a member of the public had intervened to stop her jumping off a bridge.
Following this, Nonita was hospitalised, and had three further hospital admissions before her death. The inquest heard that, during her first hospitalisation, Nonita told a doctor she planned to die in front of a train where no-one could intervene to stop her.
Before her discharge from hospital, Nonita had asked to live with foster carers, something the inquest heard was a protective factor for Nonita. However, no foster carers were available for her.
In May 2023, LBB moved Nonita to The Singhing Tree in Harrow, a privately-run supported accommodation. At that time, supported accommodation for looked after children was unregulated.
The inquest heard that the Operations Director of the home had no social work qualification, had no training in autism and last attended safeguarding training in 2021 or 2022.
In June 2023, Nonita told the owner of The Singhing Tree that she was concerned about being seen at a nearby fenced railway station. This was close to a local park that Nonita spent a lot of time in.
The Singhing Tree provided monthly reports to LBB; July 2023’s report to the council noted Nonita’s conversation about the nearby train station.
Both representatives of the supported accommodation told the inquest had they known about Nonita’s previously expressed intention to die on train tracks this would have made them question the suitability of their accommodation, given its close location to train tracks.
They also gave evidence that they were unaware of Nonita’s 2022 statement that she would take her own life when she turned 18. The operations director added that he had not been given or read any of Nonita’s care plans, despite a legal duty for this to be shared by the council.
In July 2023, Nonita was hospitalised for six days following a serious self-harm incident. Neither this nor Nonita’s fears about being seen at the nearby railway station were discussed among professionals in subsequent statutory reviews of her welfare.
Despite completing her GCSEs in a specialist school for children with mental health difficulties, Nonita had no Education, Health and Care Plan (EHCP). She was not in any education or training following her GCSEs.
Key events
The inquest also heard about the key events which occurred in the months prior to Nonita’s death.
In September 2023, Nonita secured a college place to study for a Level 3 Animal Management qualification from early September 2023. However, this place was rescinded once the college received information about the support Nonita would need to complete her studies.
In October 2023, a meeting of all professionals involved in Nonita’s life took place, after which LBB’s head of corporate parenting recorded, “Nonita has shared that she is not turning 18 and that she still wants to be a child. She identifies as a child; she watches children’s television and has toys that she takes out”.
On 12 October 2023, Nonita was discharged from CAMHS without any arrangements for mental health support as a young adult.
On 19 October 2023, Nonita was finally referred to adult social care, although no assessment was made prior to her death and it’s not clear if Nonita was informed that she had been referred.
In November 2023, an EHCP assessment by an educational psychologist found that Nonita was “feeling stressed, bored and sad” about having nothing to do.
At the end of October 2023, Nonita’s relationship with her art therapist also came to an end. This was a significant relationship for Nonita.
By 11 December 2023, Nonita’s volunteer Independent Visitor with Action for Children, Katharine Bryson – a retired teacher with nearly four decades’ experience of working with children – had raised written safeguarding concerns about Nonita’s lack of enrolment in education and training and general unhappiness. These serious concerns, which Nonita empathically wanted to be passed on, were not communicated to LBB by Action for Children until January 2024, at which time Nonita had died.
Nonita’s final child in care statutory review was conducted on 4 December, followed by her 18th birthday, on 13 December. She attended a leaving care dinner on 20 December, which left her feeling “overwhelmed”. Nonita then spent Christmas Day at The Singhing Tree on 25 December.
On 28 December 2023, Nonita left her accommodation. She died shortly thereafter, having been struck by a train in north-west London, on railway tracks close to where she was living.
Coroner’s conclusions and findings
In his findings of fact, the Coroner noted that by 13 December 2023, CAMHS had decided to end its specialist mental health provision for Nonita, and she was discharged to her GP. In CAMHS’ discharge letter, it said: “It is important to consider if the level of support is reduced too quickly or if she is unprepared in future for natural life transitions, self-harm will return as this is her baseline behaviours when emotionally or sensorily overwhelmed”.
The decision by CAMHS to leave Nonita without any specialist mental health support during this critical period of transition was done before any referral made was made to adult mental health services, despite her making clear she did not want support to end and asking her specialist social worker to visit her again after their final planned visit.
The Coroner found that Nonita formed the intention to take her own life, and that the following probably made a more than minimally contribution to Nonita’s death:
1) The absence of co-ordinated transition from secondary school to college as a looked after child, resulting in Nonita not being in education for the four months leading to her 18th birthday and lacking a sense of purpose – both of which were triggers for her suicidal ideation.
2) The absence of a co-ordinated transition out of CAMHS as a highly vulnerable looked after child, leaving Nonita without any specialist mental health support from 13 December 2023 as she approached a known and dangerous crossroads in her life.
3) The absence of a co-ordinated transition out of children’s social care, resulting in several key decisions for Nonita’s future being unresolved or unconfirmed by the time of her 18th birthday. This included funding for her residential placement, referral to adult social care, her education and immigration status. Uncertainty and isolation were known to cause Nonita distress and anxiety.
4) The absence of co-ordinated information-sharing between the various agencies involved in Nonita’s care which inhibited effective assessment and management of the risk Nonita posed to her life as she transitioned into adulthood and out of care.
The Coroner will be issuing a Prevention of Future Deaths report to London Borough of Barnet and North London NHS Foundation Trust in relation to the lack of transitional support.
Katharine Bryson, volunteer at Independent Visitor, said: “Nonita was a vibrant, talented young person who loved animals and was seeking a purpose in life. She had recently achieved a good set of GCSEs and had aspirations to work with animals, something she sadly never got to realise. I believe with the right support in place, she could have lived a full life.
It is shocking to me that so little support was in place to help Nonita cope. It is tragically too late for Nonita, but I am also aware that there are hundreds or indeed thousands of young people living in conditions such as Nonita, where they are not part of a family or receiving adequate (if any) care and support. These young people deserve so much more than they are currently receiving.”
Carolyne Willow, Senior Children’s Rights Advisor at Article 39, said: “The inquest process has laid bare a litany of failures in the state’s discharge of its legal and moral obligations towards this highly vulnerable young person, when she was still a child and in the first two weeks of her short adult life.
The fatalism and inertia among agencies displayed before the court – relating to the unavailability of fostering for older children, delay in securing education and training, and the high hurdles young people must get over before being provided adult social care and mental health support – while understandable, should never become acceptable. If the term ‘corporate parent’ is to have any meaning, then the Coroner’s findings as to what may have prevented Nonita’s death should have every local authority across the country checking in and on the children in their care who are approaching adulthood.
It beggars belief that a child with Nonita’s exceptionally high level of vulnerabilities, and known risk of suicide, was placed in unregulated accommodation where she could not legally receive any day-to-day care, and that so many critical aspects of her life remained uncertain as she approached her 18th birthday. We look forward to making submissions to the Coroner on the content of his report setting out how future deaths of young care leavers in these kinds of circumstances could be prevented.”
Deborah Coles, Executive Director of INQUEST, added: “It’s shocking to see how someone with such vulnerability, surrounded by so many professionals, could fall through the cracks—with such catastrophic consequences. A young life with so much potential was failed by those who should have been there to protect and support her.
It is also vital that when care leavers die while still effectively in the care of the state, there is proper scrutiny to ensure learning and prevent future deaths. The fact it took two NGOs to secure this level of scrutiny reflects a system that too often sees these deaths as inevitable.
We welcome the coroner’s recognition under Article 2 that the state, as corporate parent, owes a clear and enforceable duty of care to those in its charge. This is a vital acknowledgment—not just of the rights of Nonita, but of the responsibilities that must be upheld by those entrusted with her care.”
Additional media
For further information, please contact Alex Blair, Communications Manager at Garden Court North Chambers: ablair@gcnchambers.co.uk
