A 13-year-old schoolgirl was 'crying out for help' when she took her own life after reporting a sexual assault and being denied a hospital bed.
Ella Murray was in need of help from social services, but a lack of communication between agencies meant she wasn't offered a hospital bed.
An inquest into her death heard she had a history of self-harm harm which saw her taking an overdose in 2022 and in 2023, while she was also seeing a counsellor between April and July 2023.
This came after she was referred to school counselling services for low mood and suicidal ideation, who in turn referred her to social services having told a member of staff about an alleged sexual assault.
In November that year, Ella was taken to hospital and told nurses she wanted to be admitted but a decision was taken to have her seen by a mental health nurse at home.
She was later found hanging in her room and died on November 15, 2023, in hospital.
Catherine Wood, area coroner for Mid Kent and Medway, described the teenager's home life as 'complicated', with Ella telling a nurse she was scared of her stepfather. There was no evidence that Ella's stepfather was connected to the alleged sexual assault.
Ms Wood added that steps weren't taken to ensure her safety after she went to hospital.
A fundraiser was launched in Ella's memory for Air Ambulance Charity Kent Surrey Sussex which raised over £6,000.
Ella Murray was in need of help from social services, but a lack of communication between agencies meant that she wasn't offered a hospital bed
It was then arranged for her to be taken to Medway Maritime Hospital in Kent with a high-risk mental health form by her stepfather.
Whilst at the hospital, she reported her mood as low, that she was self-harming and had suicidal thoughts, before asking for hospital admission.
However, assessed as medium risk, it was decided she would be seen at home by the mental health team.
That evening, after an argument with her parents, she ran away barefoot.
The police were called and Ella told them she feared her stepfather and didn’t want to go home.
While still on the call, her mother arrived, took her home, and gave the call handler their address, and police followed up the next morning.
She stayed home from school, and a mental health team member visited that afternoon.
Ella told the nurse who saw her she was 'frightened' of her stepfather.
She also told the nurse that she 'did not want to be in the family home and would rather go to prison and would harm herself or others if she had to stay at home'.
The nurse then contacted a safeguarding team and made a referral to social services.
Ms Wood noted that this decision was made after she left Ella’s home, and no urgent action was taken to admit Ella to hospital or involve social services about removing her from the home.
Ella was later found by her mother in her room.
Paramedics were called and did chest compressions on her and she was rushed to Kings College Hospital in London, where she died on 15 November 2023.
Her cause of death was found to be asphyxia due to hanging.
The inquest into her death heard she had a history of self-harm harm which saw her taking an overdose in 2022 and in 2023 as well as seeing a counsellor between April and July 2023. Pictured: Kent & Medway Coroner Service
Ms Wood concluded there was a 'failure' to carry out an 'adequate' risk assessment.
She said had steps been taken to share information between the school, social services and mental health providers then 'she may have been removed from her home and may still be alive today'.
Ms Wood was informed that the new Children's Wellbeing and Schools bill includes a duty to share information to promote safeguarding.
'If a multi-agency meeting had been convened this may have prevented Ella's death and such action may reduce the risk of death for other children being in a similar position,' the coroner said.
The coroner sent her report to the Department of Health and Social Care, NHS England and Kent and Medway Integrated Care Board.
An NHS England spokesman said: 'The NHS England South East regional safeguarding team will, through established governance arrangements, have oversight of Kent and Medway Integrated Care Board's actions to implement the learning to improve safeguarding at both the Local Safeguarding Children Partnership and within all commissioned services.
An NHS Kent and Midway spokesman said actions have been taken to address the concerns raised by the coroner, including formulating a child-focused safety plan which will be shared with a child's school and social worker if identified.
The North East London Foundation Trust has also developed an escalation flow chart for professionals to include a Single Point of Access contact and a Multi-Disciplinary Team meeting escalation process.
The 13-year-old had reported an allegation of sexual assault
In a Prevention of Future Deaths Report, Ms Wood said: 'Social services did not speak to Ella in July and having spoken to her mother, considered that she did not reach their threshold for engagement and the school raised their concerns about this at the time.'
She was seen by a crisis team from mental health services after her overdose in August 2023, but declined further support from them. It was unclear if this was Ella's decision alone or in combination with her parent's choice
In school, Ella was said to be 'struggling' and said she wanted to move schools, the coroner said.
In September, a referral was again made to social services, and Ella revealed the name of the person she said assaulted her.
The school then involved the police, which sparked a conflict between the school and the home as to the best way to deal with the situation as well as Ella's behaviour at school, including not attending lessons.
On a weekend in November, the teenager returned from a sleepover with friends and her parents found messages which they thought were 'inappropriate'.
She then told school staff the following Monday that she wanted to take her own life.
For confidential support, call Samaritans on 116 123, visit samaritans.org or visit https://www.thecalmzone.net/get-support
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