FAILINGS were made in the care of a teenager with a “chronic risk of suicide” who died after she was hit by a train, an inquest has heard, writes Sophie Halle-Richards (MEN Media).
Eve Cockburn was 16 years old when she deliberately stepped in front of a train near Greenfield Station in September 2018.
Eve was diagnosed with anxiety and depression at the age of 14, an inquest into her death at Rochdale Coroner’s Court previously heard.
Miss Cockburn had also been told that she had Autistic Spectrum Disorder (ASD).
The teenager, who dreamed of studying at Oxford University, had been admitted to a psychiatric ward at Fairfield Hospital on two occasions and sectioned under the Mental Health Act.
Her parents believe their daughter was not provided with suitable treatment for a child suffering with autism and anxiety.
Rachel and David Cockburn told the Heywood inquest they felt this contributed to the deterioration of their daughter’s mental health.
After hearing five days of evidence, Area Coroner for north Manchester Catherine McKenna concluded Miss Cockburn died as a result of suicide. She identified key failings in the care of Miss Cockburn.
Ms McKenna said there was a failure by the local Oldham social care team to undertake a ‘meaningful’ assessment in Eve’s case.
The court heard Miss Cockburn was at a risk of social isolation and the social care team could have provided vital assistance.
Ms McKenna also highlighted an “inexcusable” failing by Saddleworth School to put a suitable plan in place for when the autistic teenager left.
The inquest previously heard school had been of great importance to the teenager and the thought of leaving ‘terrified her.’
In the days leading up to her death, Eve had been living at her home in Saddleworth with her parents and twin sister.
On the afternoon of September 4, 2018, she left her home and made her way to a section of train track near Greenfield Station.
Shortly afterwards, she was hit by a train.
A note of intent addressed to her family was found by police at the scene and at Miss Cockburn’s home address.
Mrs Cockburn described her daughter as a ‘lovely’ child who had a happy and healthy childhood.
Eve excelled at school and was said to enjoy creative writing, with the hope to become an author.
Mrs Cockburn said she noticed a change in her daughter’s behaviour on a family holiday when Eve was 14.
Her parents took her to see a GP and Eve was diagnosed with anxiety and depression.
By December 2017, Ms Cockburn said her daughter’s mental health began to deteriorate.
The court heard the student was ‘terrified’ about leaving school and had recently been diagnosed with Autistic Spectrum Disorder.
In February 2018, Eve was admitted to the Hope Unit at Fairfield Hospital, after she disclosed to a therapist plans to kill herself.
The unit is an acute psychiatric ward for patients between the ages of 13 and 18.
Her father, David Cockburn, said he did not believe this unit was appropriate for someone with anxiety and ASD.
Miss Cockburn was re-admitted to the Hope Unit in April 2018, after telling a friend she had made plans to end her life.
Due to a lack of beds, she was transferred to a unit in Warrington before being transferred back to the Hope Unit.
The court heard many patients on the ward were suffering with psychosis and this upset Eve.
She was subject to 15-minute observations, meaning interaction with her family was regularly interrupted.
Eve was discharged in May but during a holiday to Scarborough in July she was reported missing after failing to return from a trip to the beach.
She was found by police around 12 hours later suffering from hypothermia and was admitted to hospital in Scarborough.
Miss Cockburn remained there for a week before being discharged home.
By this time, her Mrs Cockburn had become extremely concerned about her lack of ability to support Eve.
Mrs Cockburn told the court that missing lessons and the uncertainty of plans after secondary school were causing Eve distress.
The inquest heard that an Educational Health Care Plan was not submitted by Saddleworth School until the last day of term.
This meant no plan was put in place for Eve’s future education on leaving school in 2018.
A spokesperson for Saddleworth School said: “It was with great sadness that we learned of Eve’s death on 4th September 2018; Eve was much loved at Saddleworth School, and her teachers still think of her.
“The inquest concluded that the school should have acted more quickly in producing an Education Health Care Plan to prepare Eve for post 16, and we must learn from this criticism and amend our practice.
“However, it has to be said that every possible measure was put in place to support Eve and her family when she was in school, and especially when she returned from hospital and during her GCSE examinations.
“Even now this includes a strong and lasting bond between her form tutor and the family.
“It is reassuring to note that Eve’s mum is quoted saying ‘I would also like to praise the pastoral support at Saddleworth who were in close contact with us and helped and adapted well to Eve’s needs, especially during her GCSE exams’.”
Gerard Jones, Oldham Council Managing Director of Children and Young People, said: “We would like to give our deepest condolences to Eve’s family at this very difficult time.
“The Coroner’s verdict was one of death by suicide and while Eve was supported by a number of agencies the actions of one agency did not contribute to her death.
“The Coroner stated they were reassured that processes are underway to ensure necessary lessons are learnt from this tragic case and we, along with our partners, will play our part in this.
“We hope our commitment to learn lessons helps Eve’s family as they try and deal with her tragic death and our thoughts are with them now and in the future.”
Helplines and websites
Samaritans (116 123) samaritans.org operates a 24-hour service available every day of the year.
For support for people feeling suicidal, if you are concerned about someone or if you are bereaved by suicide see shiningalightonsuicide.org.uk
Childline (0800 1111) Calls are free.
PAPYRUS (0800 0684141) is a voluntary organisation supporting teenagers and young adults who are feeling suicidal.
Beat Eating Disorders: These helplines are free to call: Adult Helpline: 0808 801 0677, Studentline: 0808 8010811, Youthline: 0808 8010711. www.beateatingdisorders.org.uk
Anorexia & Bulimia Care: Helpline: 03000 111213. www.anorexiabulimiacare.org.uk
Students Against Depression is a website for students who are depressed, have a low mood or are having suicidal thoughts. studentsagainstdepression.org