Mum of tragic teen Thomas Brookes says she is ‘allowed to grieve’ as coroner notes "woeful shortcomings"
The mum of tragic teenager Thomas Brookes has said she is ‘allowed to grieve’ after a coroner highlighted 'woeful shortcomings' in the way his return home from secure accommodation was handled.
Sixteen-year-old Thomas was found dead by mum Helen Wardropper at their home in Westheath Avenue, Grangetown, on Saturday, September 28, 2019.
Post mortem toxicology tests revealed he died of an overdose of heroin and zoplicone.
Speaking after today’s verdict recorded a conclusion of misadventure, Ms Wardropper said: “I am allowed to grieve for my son after two years,” she said.
"To be allowed to grieve is important. For any family, being part of this process is extremely difficult – I am relieved it is over.”
The inquest had heard a decision had been taken by children’s service organisation Together for Children to place Thomas in secure accommodation in the city in an effort to stop him obtaining drugs – the second time he had been placed away from home.
Eventually, with staff no longer legally able to stop him from accessing drugs and his mental health suffering, it was agreed he could return home despite the risk he might relapse.
Recording a conclusion of misadventure at Sunderland Coroner's Court on Thursday, September 23, at the end of a four-day hearing, assistant coroner Karin Welsh said she had identified a number of shortcomings around Thomas’s placements and especially his return home.
"Necessary documentation was not completed, particularly Placement with Parents regulations,” said Ms Welsh.
"The reason it is important to accurately record and complete necessary paperwork is to ensure that others within the organisation have a good understanding of what is happening and why.
"Of particular relevance is the lack of an updated risk assessment. A lot of reliance was placed on Helen. Whilst I have no doubt about her capabilities as a mother, was there any assessment of any support she might need in order to support Thomas?”
She also highlighted the lack of an interim plan with mental health services and the failure to pursue a planned psychological assessment for Thomas.
"The return home should have been much better managed and supported,” said Ms Welsh.
"The vast majority of these points had at their core a failure of communication.”
But she did not conclude any of the problems identified had led directly to Thomas death: “I have looked very carefully as to whether, if things had been done differently, it would have altered the outcome for Thomas,” she said.
“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 this 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 identified. My conclusion must, therefore be one of misadventure.”
Giving evidence at Sunderland Coroner’s Court this morning, Ms Wardropper said she had felt left to cope on her own with the mental health fall-out when Thomas returned home and felt she was in ‘constant crisis’.
“Together for Children had put Thomas on two placements, made everything significantly worse, then gone ‘Here you go, you deal with it’ – that’s how it felt,” she said.
"There was no safety net. There was no safety net at all for me and Thomas. If anything, we were more vulnerable as a family because of all the emotional damage that had been done.
"I believe Thomas’ risk of taking his own life was the highest it had ever been.”
Because the care order remained in place, Thomas had lived in constant fear that he could be taken away from home and returned to a placement at any time.
"He was upset, he was very nervous that Together for Children would come back and take him away from home,” said Ms Wardropper.
"Thomas was just waiting for Together for Children to pounce.
"I was in constant crisis all the time – I don’t feel like I came off red alert at all.”
The court heard Ms Wardropper has previously suggested Thomas could come home if sufficient help was in place and had requested that should include mental health support from the Children and Young People’s Service, resumption of cognitive behavioural therapy and access to the Youth Drug and Alcohol Project.
Asked by her solicitor Ruth Bundy if any of these had been put in place, she replied: “Not at all.”
Together for Children director of children’s social care Martin Birch said the organisation had introduced a raft of changes in recent years and had been graded ‘Outstanding’ on its latest Ofsted assessment.
The service had been in a state of flux at the time of Thomas’ return home: “It was quite a difficult time,” said Mr Birch.
"A lot of the senior management team were just coming in.”
The inquest had heard a care report recommended Thomas be given a psychological assessment, but this had never happened. Together for Children had now appointed an in-house psychologist so it was no longer reliant on outside resources.
A statement from Sunderland Safeguarding Children Partnership – which includes Sunderland City Council; Sunderland Clinical Commissioning Group and Northumbria Police – after today’s conclusion 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.”