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East Anglian Daily Times
13:34 10 September 2014
The parents of a Suffolk teenager who died last month following a long battle with anorexia and depression have told of their determination to raise awareness of the illness, which claims hundreds of young lives every year.
Charlotte Cobbald, 17, passed away on August 4 after collapsing at the family farm in Acton, near Sudbury.
The former Ipswich High School for Girls student, who received top grades across the board in her GCSEs and demonstrated a huge talent for sheep farming, had previously spent six months in The St Aubyn Centre in Colchester receiving treatment for anorexia.
Her parents Stephen Cobbald, a former Suffolk Show president, and Hilde Cobbald are now on a mission to get the disease moved up the healthcare agenda, both at national and local level.
Mr Cobbald said: “Anorexia is a dreadful illness that kills hundreds of teenagers every year and yet so little is known or understood about it.
“Until Charlotte developed the eating disorder, we didn’t understand it either. Most people’s understanding of anorexia it is that it’s a dietary related problem of teenage girls who think they are fat – but nothing could be further from the truth.
“In 2012/13, cases of anorexia increased in Suffolk by around 20% making it one of the fastest growing diseases, and yet only 1% of the country’s healthcare budget is spent on mental illness.
“It’s too late for Charlotte now, but Hilde and I are determined to do something to raise awareness. We want something to be done at top level and that’s why we have arranged a meeting with the Health Minister Norman Lamb in October. If we can save just one person, then it will be worthwhile.”
Via a memorial fund, more than £1,000 has already been donated to The St Aubyn Centre in Charlotte’s name. The Cobbalds hope to start a campaign to raise enough money to pay for a minibus to enable young people at the unit – one of the only specialist centres of its kind in the south of England – to get out together and enjoy a “better quality of life”.
Mr Cobbald continued: “We are hoping that with a push we can generate even more funds for teenagers trapped within this dreadful disease.”
In addition, Charlotte’s parents want to continue the work their daughter started in the farming. The popular teenager bred prize-winning Texel sheep and had a small flock.
The Suffolk Young Farmers Club hopes to hold an annual training day in livestock handling and judging with a competition at their annual rally, and her family would like to do something for young people at the Suffolk show, financed by Charlotte’s Trust.
Mr Cobbald added: “More than 500 people attended the memorial service held for Charlotte – she was a special person who touched the hearts of so many.
“Charlotte had a special talent for, and love of, sheep dog trialling and was a member of the East Anglian Sheepdog Club.
“Charlotte has already given a flock of 25 sheep posthumously to Otley College – the Charlotte Cobbald flock – to raise awareness of the opportunities there are in farming for young people. Hilde and I would like to encourage and nurture the talents of other young people in the area and nationally if there’s an opportunity.”
Charlotte’s mother added: “Charlotte is missed terribly by not only her family, but also by so many people she knew and met. We feel it is so important that she continues to make a difference as she hoped to in life.”
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Suffolk Safeguarding Children Board Serious Case Review
Independent Overview Report Writer: Briony Ladbury
1.2.1. On 18th August 2014 the Suffolk Local Safeguarding Children Board (Suffolk LSCB) SCR Panel was alerted to the death of a young person which had occurred on 4th August 2014 in Suffolk.
2.1. Introduction to Young Person C
2.1.1. A sense of Young Person C was drawn from conversations with her parents and many of the staff who looked after her. The wishes feeling and views of Young Person C, according to the verbal accounts of staff, were central to the professional interventions undertaken as part of her treatment, but in general they were poorly represented in the documentation provided as evidence for this review.
2.1.2. We learned that Young Person C’s parents were married but had separated soon after Young Person C’s birth. She was the only daughter of that marriage. Her father is a sheep farmer in Suffolk, and farming was an important part of her life. Young Person C had three adult step brothers. Two of her step brothers, who were much older than Young Person C, lived abroad and had occasional contact with her, including during the timescale of this review.
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2.1.3. Following her parents’ separation, Young Person C stayed with her mother and was the subject of a residence order, although contact with her father was maintained throughout her early years. By the summer of 2011 Young Person C made a choice to live with her father on the farm. This arrangement however broke down in May 2012 and Young Person C moved back to her mother’s house with her father’s agreement. As a very busy farmer and an older parent, Young Person C’s father realised he had little experience and was not coping well with meeting the needs of a teenage daughter.
2.1.4. The loss of both of Young Person C’s grandparents within a few weeks of each other when she was fourteen years old had a profound effect on her. Young Person C’s mother also struggled to cope with the loss of her parents and Young Person C felt particularly isolated at this time.
2.1.5. Young Person C’s parents were able to, and often did, arrange private healthcare for various ailments during Young Person C’s childhood, and especially following a skiing accident when she sustained a broken leg. She also attended an independent school in Suffolk as a day pupil.
2.1.6. We have heard consistent descriptions that Young Person C was a likeable, bright, intelligent, and popular young person, who was a perfectionist and somewhat impatient by nature. She enjoyed sport and the outdoors and was a successful long distance runner.
2.1.7. We also heard that Young Person C had high expectations of herself and became easily frustrated and disappointed if she failed to achieve the goals she had set herself. Changes to friendship groups and actions of peers at school also affected her deeply and perceived disloyalty caused her great anguish.
2.1.8. Farming was a constant and important factor in her life. She was interested in and knowledgeable about rearing livestock and training sheep dogs and she was a popular and active member of the local Young Farmers Association.
2.1.9. Young Person C hoped to assume a career in farming, agriculture or veterinary science and was working hard at school to achieve this, successfully attaining good grades in her GCSE examinations in the summer term of 2013.
2.2.2. The complexity of the family dynamics between Young Person C and her parents is a continuous feature in the SCR chronology and reports. Despite obvious relationship difficulties there was also ample evidence that both her mother and father loved her deeply, but they admitted that they found the challenges of looking after Young Person C demanding and difficult. During the acute phases of Young Person C’s illness she projected a lot of anger and negativity onto her parents, particularly her father, but in the periods of improvement she appeared well attached to both of them.
2.3. HM Coroner’s Inquest
2.3.1. The Coroner’s Inquest took place on 2nd April 2015. The Assistant Coroner described a narrative conclusion acknowledging the events that happened on the day of Young Person C’s death and her significant history of mental illness. It was indicated that there was insufficient evidence to be sure that Young Person C had intended to take her own life at the time of the incident and that her action may have been a cry for help. The cause of death was confirmed as toxicity from the animal medication.
188.8.131.52. The first contact with the NSFT CAMHS service was on 13th February 2013. An emergency referral was faxed to the service from the GP after Young Person C’s mother had found her daughter viewing on-line suicide websites at home. The referral was accepted by the NSFT CAMHS triage service the following day and Young Person C’s mother was contacted for consent to start a mental health triage assessment.
184.108.40.206. A letter informing the GP of the outcome of the triage assessment was sent to the GP the following day and a similar letter was sent to the school explaining that an emergency specialist CAMHS assessment had been requested. The letter alluded to a possible diagnosis of severe depression with a danger of self-harm.
220.127.116.11. By the 14th February 2013, two days after the initial referral, the request for an urgent assessment had been received and a specialist CAMHS appointment was arranged for five days later on 19th February 2013. Details of the appointment were posted to Young Person C’s mother along with documents for Young Person C and herself to complete ahead of the appointment, including strengths and difficulties questionnaires (SDQs) designed to help Young Person C and her mother to think about the aspects of C’s life that were impacting on C’s health and wellbeing, and to help them both articulate their feelings.
18.104.22.168. The first specialist CAMHS appointment, which occurred on 19th February 2013 as planned, consisted of an assessment by a psychiatrist and a nurse. Young Person C attended with her mother bringing the necessary completed documents and the SDQs with them to inform the assessment. A full history was taken from Young Person C and her mother. The decision by the locum psychiatrist was to continue to review Young Person C at the clinic with a view to prescribing medication for her anxiety and depression and to decide if Cognitive Behavioural Therapy might be an option for her.
22.214.171.124. The second outpatient appointment on 28th February 2013 resulted in anti-depressant medication being prescribed. Cognitive Behavioural Therapy (CBT) was considered to be a suitable future treatment option. Further appointments to review Young Person C’s progress were recommended. A letter was posted to the GP giving a comprehensive account of the assessment that had taken place.
126.96.36.199. A pattern emerges shortly after the family has engaged with the CAMHS service, of Young Person C’s mother leaving messages on the answer phone at the specialist CAMHS clinic reporting that all was not well with her daughter. The messages left between February 21st 2013 and the 4th March 2013 (a period of eleven days) were written down on receipt and passed to the psychiatrist or nurse for their attention. The messages indicated a high level of parental anxiety and related to increasing concerns about Young Person C’s suicidal ideation and selfharm. One message described how Young Person C had tried to jump out of her mother’s moving car. In all, five telephone messages were left for the team about Young Person C’s difficulties and worsening behaviour.
188.8.131.52. The reason why there seems to be a lack of focus on important issues, about self-harm in particular, that were known and recorded remains unexplained. From the information supplied in the chronology it appears the matter was noted as a discrepancy. The Trust’s acknowledgement of a disparity between the reports of self-harm on 12th March 2013 and the assessment of 14th March 2013 needs to be further explored as it may be connected to a systems failure. Any subsequent findings and recommendations should be included in the NSFT single agency action plan for the LSCB.
184.108.40.206. Young Person C decided to discontinue her individual sessions with the private clinical psychologist on June 17th 2013 and a letter dated 25th July 2013 was sent from the clinical psychologist to the GP after completing 7 sessions. The clinical psychologist described a huge improvement in Young Person C’s mood and her relationship with both of her parents, possibly because she no longer felt stressed about her examinations…
220.127.116.11. At the end of June 2013 Young Person C’s mother telephoned the specialist CAMHS service to report that Young Person C was no longer taking her medication; this is recorded in the file.
18.104.22.168. Numerous attempts to harm herself were observed and recorded by staff and the methods were extreme and varied. The self-harm attempts were recorded in full in the patient notes, but not always logged as an accident/incident according to the procedure that the Priory Hospital requires as part of its organisational risk management and learning and improvement framework. 22.214.171.124. By February 5th 2014, Young Person C’s risk assessment escalated to deliberate self-harm and suicide ideation with intent. The staff tried hard to manage the risk to Young Person C by increasing her supervision and observations, for example one-to-one supervision when awake and 6 checks per hour at night. Items that she could harm herself with were removed. 126.96.36.199. Nevertheless on 10th February Young Person C was found with a ligature (scarf) round her neck. Young Person C was examined by a doctor immediately. This action was to assess any immediate medical needs and was entirely appropriate. Staff comforted Young Person C and her mother was called, who travelled to the unit to be with her daughter. Young Person C was re-assessed as a suicide risk and monitoring was increased to one-to-one within eyesight at all times 188.8.131.52. Young Person C’s mental health continued to deteriorate and consideration was given to whether hospitalisation was aggravating Young Person C’s sense of hopelessness. Reaching a point where hospitalisation in itself becomes a risk is not uncommon. As Young Person C’s mother had reported that Young Person C often became distressed at the thought of returning to the unit after home leave, it seems reasonable to have incorporated this as a factor in her risk assessment.
184.108.40.206. The Priory Hospital felt that their service was not the right environment to manage Young Person C’s escalating and serious deliberate selfharm. The notes record in full the various ways and means that Young Person C employed to hurt herself, and despite numerous risk assessments and plans it was clear that the hospital was struggling to keep her safe. By the 17th February the Priory Hospital made the Page 47 of 69 decision that Young Person C needed to be in a more secure environment and the plan was communicated to her parents.
220.127.116.11. Young Person C’s parents were understandably concerned by this decision, which could involve their daughter being moved to a unit many miles away. Both parents expressed a wish to be involved to support their daughter through this most traumatic time.
18.104.22.168. In the early hours of the 19th February 2014 Young Person C became extremely agitated and disclosed that she was struggling to control the urges to kill herself. At 03.35, Young Person C was found once again to have tied a ligature tightly round her neck. The ligature had restricted her breathing slightly and she was placed on oxygen. The examining doctor took immediate advice from an Ear Nose and Throat specialist about Young Person C’s immediate care, ensuring that her medical needs were met in full.
22.214.171.124. Despite frequent risk assessments and attempts to keep Young Person C safe, the service at the Priory Hospital was clearly not able to meet her complex needs and arrangements were quickly made for Young Person C to transfer to a more secure unit.
126.96.36.199. In July 2014 Young Person C’s condition was again showing signs of improvement and leave opportunities that were granted proceeded with no adverse effects or incidents. Young Person C was receiving regular visits from both her parents and the staff on the unit remarked on how well they were all getting on. At a multi-agency CPA meeting on 11th July 2014 her parents expressed how pleased they were with their daughter’s progress, how helpful and supportive the staff had been and how they had appreciated being involved in Young Person C’s care plan. At the same meeting, Young Person C spoke optimistically about her future, outlining reasons why she should refrain from hurting herself. She talked about running her own farm and going to agricultural college, and was pleased by the improving relationship with her father. 188.8.131.52. Following this meeting Young Person C’s demeanour continued to improve markedly. Staff described her as being a pleasure to have around, helpful and happy. She was joining in a range of group activities and she was clearly enjoying her parents’ company. Due to likely sudden changes of mood staff continued to follow a cautious Page 55 of 69 approach. But leave plans were acceptable to her and she no longer objected to the decisions being made by staff or resorted to self-harm as a result of disagreements or inability to change an outcome. Her relationship with her parents was visibly improving, and the staff spoke about her parents bringing Young Person C’s dogs to the unit for her to see from the window of her room, and pots with flowers.
184.108.40.206. By the time of the next review scheduled for 31st July 2014 Young Person C had spent several leave opportunities on her father’s farm that she loved. Young Person C had vast experience of the farming industry having been exposed to the family farm and watching and later working alongside her father. It was a very important part of her life and was the career she wanted to pursue. Young Person C was highly skilled in undertaking complex farming work and whilst on leave enjoyed several farming related activities such as driving a combine harvester, shepherding and horse riding which were second nature to her. She had enjoyed the trips to the farm immensely and they had all passed without incident. 220.127.116.11. Many staff on the unit admitted they had no personal experience of farming or the hazards that a farm presents. One member of staff alluded to not being aware that animal antibiotics could be lethal to humans, and another admitted that farms and the countryside are often portrayed as healthy places to spend time; the thought of the farm that Young Person C loved causing C harm did not cross her mind. In addition they had not factored in the amount of knowledge Young Person C had about the farming industry. She would have known exactly what could cause her harm and where it would be.