Fatal Accident Inquiry into the deaths on Erskine Bridge
Summary of FAI Determination.
Sheriff Ruth Anderson QC. Sheriff of North Strathclyde at Paisley
Niamh Frances Bysouth (also known as Niamh Frances Lafferty) and Terrie Faye Oliver (also known as Georgia May Rowe) died in the waters of the River Clyde below the Erskine Bridge Renfrewshire shortly before 21.00 on Sunday 4th October 2009. Their deaths were suicides. The girls, having walked from the Good Shepherd Open Unit stopped at a point near the centre of the Bridge, at the barrier on the west side. Both girls died on impact with the water.
Evidence in the Inquiry began on 15th June 2011 and the Inquiry heard from the last witness on 19th December 2011. Evidence was heard over some 65 days.
The deaths of Niamh Frances Bythsouth (also known as Niamh Frances Lafferty) and Terrie Faye Oliver (also known as Georgia May Rowe) may have been avoided had the following reasonable precautions been taken:
- Had the number of staff members on duty at the Good Shepherd Open Unit on 4th October 2009 been at least four in terms of Regulation 13 of SSI 114/2002, the agreement between the provider and the Scottish Commission for the Regulation of Care (‘the Care Commission’), and in light of the prevailing dynamics within the establishment.
- Had Niamh Frances Bysouth (also known as Niamh Frances Lafferty) and Terrie Faye Oliver (also known as Georgia May Rowe) been accommodated in October 2009 on the first floor of the Good Shepherd Open Unit rather than in the self-contained flat on the ground floor directly opposite an unalarmed fire exit door
The following facts are relevant to the circumstances of the deaths:
- There was a need for a more robust approach to the issue of absconding linked to the security of the premises at the Good Shepherd Open Unit
- Management at the Good Shepherd Open Unit in August, September and October 2009 should have given proper regard to the serious nature of the bullying of Terrie Faye Oliver (also known as Georgia May Rowe) by AM (a young person resident in the establishment at the time) and its impact on Terrie Faye Oliver (also known as Georgia May Rowe) and management should to have taken appropriate steps to ensure the removal of either Terrie Faye Oliver (also known as Georgia May Rowe) or AM from her placement at the Good Shepherd Open Unit
- The failure of placing authorities to hold detailed, comprehensive, concise and readily accessible information relating to an individual child to include the recommendations of the child’s social worker/key worker and any psychological assessment, and to ensure this information was copied to the residential establishment on any placement of the child.
- There was a need for systems of communication (both verbal and documentary) to be set up and adhered to by all staff responsible for the care and safety of young persons to ensure that accurate and up-to-date information relating to an individual child was available to decision makers and to those responsible for day-to-day care
- The need for a ‘stand alone’ risk assessment in documentary form for each young person in the care of a residential institution with separate consideration given to the issues of ‘self-harm’ and ‘suicide’.
No ‘stand alone’ risk assessment was ever done on either Niamh or Georgia by their placing authorities nor by any of the residential establishments in which they were placed. Had such an assessment been carried out, regularly updated, and accompanied each girl to the various establishments in which she was placed, then management and staff charged with their health and safety would have had a readily accessible and comprehensive document as a valuable tool to assist them in their responsibilities and to alert them to the risks which pertained, whether those were in relation to absconding, self-harm or suicide.
The Inquiry heard from Professor Stephen Platt, Professor of Health Policy Research at the Centre for Population Health Sciences at the University of Edinburgh. One area of concern for him was why, given the case histories of both Niamh and Georgia, no judgement as to the risk of suicide was ever reached by those in the Open Unit. In his conclusion he makes three preliminary recommendations which may benefit those responsible for the welfare and safety of young persons in their care.
1. Local authorities should commission a set of guidelines for staff working with looked after and accommodated children about recognising and mitigating suicide risk in this client group. These guidelines should include the requirement to develop a detailed management protocol.
2. The management protocol should set out the procedures to be implemented when a looked after and accommodation child is considered to be at risk of self-harm or suicide e.g. by making suicide ‘threats’, by expressing suicidal thoughts or by making preparations for suicide. The protocol should cover inter alia the allocation of duties and responsibilities, effective methods of communication, within the establishment, liaison with other professionals and techniques for preventing contagion/spread of suicidal behaviour within the establishment.
3. Professionals working with looked after and accommodated children, either directly (e.g. in residential establishments) or indirectly (e.g. local general practitioners or employed in the local CAMHS team0 should have a sound understanding of the risk of self-harm and suicide among their clients and of appropriate interventions to mitigate that risk. Appropriate training should be provided on starting employment in a residential centre and at regular intervals thereafter (as part of continuing professional development).
“I would wish once more to express my sympathy to the families of Niamh and Georgia and to put on record how grateful I am for the way in which those who attended the Inquiry conducted themselves throughout, both in the giving of evidence, and in the way they conducted themselves during the many days of evidence, much of which must have been distressing for them all. They behaved with dignity and restraint throughout”. Sheriff Ruth Anderson QC
The full Determination is now available here.