‘Woeful shortcomings’ found in Sunderland service meant to help boy, 16, who died of drug overdose

A coroner has criticised “woeful shortcomings” in a Sunderland’s children’s service – but admitted they could not be directly linked to the tragic death of an “amazing” teenager.

Thomas Brookes, 16, was found dead by his mother Helen Wardropper at home in Grangetown, Sunderland, in September 2019.

On Thursday, Sunderland Assistant Coroner Karin Welsh recorded a conclusion of death by misadventure, following a four-day inquest which heard Thomas had died due to the effects of an overdose of heroin, as well as the sleeping pill zopiclone.

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“Bright and able” Thomas had been using Class A drugs since he was 13, although he used them intermittently and was thought to do so as a “coping mechanism” rather than being addicted.

In the two years preceding his death, the inquest heard, Thomas had become involved with Sunderland’s Together for Children service, as well as mental health services, as a result of his problems with drugs.

In June 2019, Thomas was placed into temporary secure accommodation in a rented property in Sunderland – a situation which was known to be “unsuitable”, but which was the only option due to a lack of secure care facilities for children across the country.

Initially meant as a temporary measure, Thomas spent seven weeks at the property. But with his mental health severely impacted by the stay and staff no longer legally able to stop him from accessing drugs, it was agreed he should return home where he could be supported by his mother.

Ms Wardropper told the inquest her son’s stay in the rented property had been a “horror story”. And when he returned home she said the extra support he needed after the experience was not present.

She said: “There were times I honestly thought I would get a call from [the property] saying that Thomas had taken his life. There were messages that Thomas sent to me that were brutal for me to read.

“When Thomas came out he was in huge distress… I fully anticipated there would be risk assessments done, there would be that immediate package of support, I fully expected that Thomas would be home and [Together for Children] would be at my front door that day or very soon after.”

In the two months between Thomas’ return home and his death, his mum said she was constantly “on red alert”.

“I felt worse at the end of the process,” she said.

“I felt more vulnerable as a parent, I felt more frightened. If anything the situation was ten times worse and I was even more frightened for Thomas’ life.”

A previous placement away from home, in Cumbria, had also been “detrimental” to Thomas, the coroner found – despite keeping him away from drugs it had left him “isolated” from his loved ones and had done “little to address underlying issues”.

When Thomas returned home, a care report recommended he be given a psychological assessment, but this never took place.

Meanwhile, Ms Welsh said “necessary documentation” for placing children with parents was not completed; Thomas’ care plan wasn’t updated and an updated risk assessment wasn’t carried out.

The coroner added: “The vast majority of all these points had at their core a failure of communication.”

She noted that Thomas had had eight different social workers, which she said was “simply not good enough”.

Addressing the inquest, Martin Birch, Together’s for Children’s director of children’s social care, said the service had been rated ‘inadequate’ at the time by Ofsted, but has since progressed to ‘outstanding’ with a number of improvements made. Among these were an increase in the number of permanently employed social workers and an in-house psychologist who could carry out assessments.

Despite criticising several aspects of the service, Ms Welsh said that even if there had been the “ideal” package of support envisaged by several of the workers who had worked positively with Thomas and his family, there would still “be a lot of ‘what ifs'”.

She said: “I have looked very carefully as to whether if things had been done differently it would have altered the outcome for Thomas. I must be able to identify a causal link between these identified shortcomings and Thomas’ death.

“I note in particular the unpredictable nature of Thomas’ drug use and that it was the first time that Thomas appears to have used drugs in some 17 weeks and certainly since his return from Lily Street.

“I cannot establish such a link, but that is in no way to minimise the woeful shortcomings I have noted.”

Speaking after the conclusion, Ms Wardropper said she needed time to process the outcome, but that it was a “relief” to have the inquest over so she could finally grieve properly for Thomas, who she called “an amazing son”.

A spokesperson for the Sunderland Safeguarding Children Partnership said: “This tragic death is desperately sad, and our thoughts are with Thomas’ family and friends.

“The Sunderland Safeguarding Children Partnership has co-operated closely with the inquest and having listened very carefully to what the Coroner had to say, we will be taking her comments on board when we publish a child safeguarding practice review in the near future.

“This will look in greater detail at the circumstances surrounding Thomas’ death and what happened in the weeks and months leading up to this.

“It isn’t possible to talk about this in any detail until the review is published, because the review couldn’t be completed until after today’s inquest. However, it will outline important learning from this tragic death that will help improve our work to keep children and young people safe.”

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Chronicle Live – Sunderland