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recurance

Amy El-Keria

3 Oct 2016 · Coroner Penelope Schofield · East Sussex

A similar concern from this report was raised again 1 time later. See the linked reports.

The coroner's concerns

  1. 1. lack of role understanding by Hounslow Social Services

    “The evidence given at the Inquest showed that there was a clear misapprehension by Hounslow Social Services as to their role in supporting [the deceased] whilst at Ticehurst”
  2. 2. failure to assess need for support under Section 17 Children Act 1989

    “Social Services clearly have a vital role to play in ensuring family contact where a child is placed far from their family home where difficulties arise”
  3. 3. insufficient family involvement in care

    “The family gave evidence to the extent that having better contact with [the deceased] and more input into her care may have brought about a different outcome”

Linked reports

Raised again laterJustin Gallagher16 Aug 2019 · 2 years 10 months later
Identical hazardConfidence 0.90 · high

This report

“The family gave evidence to the extent that having better contact with [the deceased] and more input into her care may have brought about a different outcome”

Later report

“There was no involvement of the family and so a source of important information was missed.”
Original on judiciary.uk ↗
Full chain: Inadequate family involvement in care

Responses

2016-0347-Response-by-Department-of-Health.pdf ↗· Department of Health and Social Care

Stated action · 2009

“The Department of Health published good practice guidance on assessing and managing risk in mental health in 2009. This can be accessed through the GOV.UK. website at the following address: https://www.gov.uk/government/publications/assessing-and-managing-risk-in-”

2016-0347-Response-by-Priory-Group.pdf ↗· Hounslow Borough Council

Stated action

“We note your comments in relation to the QNIC guidance published by the Royal College of Psychiatrists and we consider that this is still an appropriate reference point for the staffing of CAMHS units and continues to be used by many providers in determining and monitoring appropriate staffing levels.”

2016-0347-Response-from-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care

Stated action · 2020

“community where they live. NHS England and Health Education England (HEE) are working to improve the capacity and capability of workforce delivering mental health care for children and young people, so that by 2020 an additional 70,000 receive effective treatment per year. This work extends to supporting training programmes for staff working in inpatient CAMHS to improve team functioning and delivery of evidence-based care.”

2016-0347-Response-from-Priory.pdf ↗· Hounslow Borough Council

Stated action

“We note your comments in relation to the QNIC guidance published by the Royal College of Psychiatrists and we consider that this is still an appropriate reference point for the staffing of CAMHS units and continues to be used by many providers in determining and monitoring appropriate staffing levels.”

El-Keria-2016-0347a.pdf ↗· Hounslow Borough Council

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error