2 May 2024

This is a media release by Imran Khan and Partners solicitors, reshared by INQUEST

Before HM Senior Coroner Richard Travers
Woking Coroner’s Court 
Conclusion on 1 May 2024

Jennifer (‘Jen’) Chalkley was just 17 years old when she took her own life on 12 October 2021, at her home in Surrey. An Inquest into Jen’s death has found that multiple failures on the part of Surrey and Borders’ Child and Adolescent Mental Health Services (CAMHS) and Surrey County Council contributed to Jen’s death. 

Jen had an infectious smile. She used to love dancing and theatre. She was happiest when spending time with animals, whether that be riding and tending to horses at her local stables or playing with her beloved dog, Pepper. When she was 10 years old, she was diagnosed with ADHD and Autism.

Jen was first known to Surrey and Borders’ Child and Adolescent Mental Health Services in 2018, when she was 14 years old. She was referred after telling teachers at school that she was planning to take her own life. 

In 2021, the same year she died, Jen was hospitalised twice after attempting to take her own life. After each incident, Jen was referred to CAMHS. On each occasion, she received no intervention or treatment from her local CAMHS community team. 

She was twice discharged by CAMHS across a three year period, having not been assessed, diagnosed, or having had any therapeutic treatment or her medication reviewed.

Jen last discharge from CAMHS took place three months before her death, in June 2021, after a 15-minute audio call, by practitioners who had not properly reviewed her medical history. The Coroner found that one of the practitioners who discharged Jen tried to mislead him in evidence; the other was found by the Coroner to have been dishonest.  

The Senior Coroner has concluded that Jen’s death was contributed to by:

•  A failure of CAMHS to properly to assess, diagnose and treat Jen, in order to manage her conditions and minimise her risk of suicide;
• A failure of Surrey County Council's SEN department to ensure Jen’s Education and Health Care Plan (EHCP) reflected her mental needs, to ensure that the college she attended from September 2021 could provide her with support;
• A multiagency, systemic failure to work together to ensure Jen’s needs were met.

The Coroner also found that:

• There was top down pressure on CAMHS practitioners to refer patients away from the service and discharge them, rather than treat them;
•  The service was unable to meet the level of demand;
• Opportunities were missed to make an EHCP application at an earlier stage, to ensure she was in better educational setting;
• Educational establishments were misguided about the criteria for applying for an EHCP.

Jennifer’s mother, Sharren Bridges, commented at the end of the inquest: “I miss Jen every day. She was true to herself, and she made the world a better place. 

Jen was on CAMHS’s waiting list for months at a time. It always felt as though we were in a cycle. Jen would have a mental health crisis. She would then go onto the waiting list; receive minimal intervention; and then she was discharged. At no point did a practitioner listen to me about how Jen was really doing. Instead, practitioners and her teachers were dismissive of our concerns. 

I hope no other family ever has to experience what we have. Surrey Coroner’s Court have worked tirelessly to reveal the truth about the systemic, multi-organisational failures that led to Jen’s avoidable death.

I can only hope that lessons from Jen’s experience are learnt and acted upon. Surrey and Borders must not allow Jen to become just another shocking statistic. 

I love you always Jen.”

Daniel Cooper, solicitor for the Family, commented: “The evidence heard at this Inquest suggests that Surrey and Borders’ CAMHS are systemically incapable of supporting and treating young people who face mental health crises.

CAMHS were aware of Jen’s suicidality, and that she had complex needs. Rather than assessing her needs and providing her with treatment which could help her cope with her mental health crises, CAMHS practitioners sought to discharge her from their books, or refer her to services which could not support her.

Most shockingly, the culture that facilitated these failures is systemic and top down, as demonstrated by the evidence given by senior CAMHS figures at this Inquest. Additionally, the local authority failed to have proper oversight of the EHCP process, which missed another opportunity to provide Jen with the support she needed.”  

Selen Cavcav, Senior caseworker at INQUEST, said: "Jen died because nobody except her own family made it their own business to make sure that she was safe.

What is the point of having all these agencies and protocols for safeguarding children when nobody talks to each other? The current focus appears to be more about getting people of their books rather than recognising risks and providing adequate, autism informed, person-centered care.

It is shameful that as a society, the systems and structures we have in place are unable to keep Jen and other children like her safe. " 

ENDS

NOTES TO EDITORS

For further information, please contact Patrick Dunne on [email protected].

The  family is represented by INQUEST Lawyers Group Members Daniel Lemberger Cooper and Patrick Dunne of Imran Khan and Partners solicitors. Counsel for the Family is Maya Sikand KC of Doughty Street Chambers. 

Other interested persons represented at the inquest are Surrey and Borders Partnership NHS Trust, Guildford College, Surrey County Council, and a former employee of Surrey and Borders Partnership’s Child and Adolescent Mental Health Services.

Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.

Other relevant case:

• Oskar Nash, 14, died a self-inflicted death on 9 January 2020 in Egham, Surrey. He had Asperger’s Syndrome. The inquest into concluded that his suicide was contributed to by neglect from Surrey and Borders Partnership NHS Foundation Trust. Media release.