Failed: Tragic Dana Baker 'let down by system'

Worcestershire Coroner Geraint Williams said there had been 'serious systematic failings' and there was a failure to have a plan to protect her from a 'known, present and continuing risk that she would kill herself'.

She was found hanging from a tree in Kidderminster in 2011.

The sporty 16-year-old, who represented Great Britain in karate, was being fostered after it was revealed she was having a relationship with her martial arts teacher Jaspal Riat, then 49, who was later jailed for eight years for sexual abuse.

At Dana's inquest today, Mr Williams said the breakdown of her relationship with her foster carers and the perception of feeling rejected was recognised by all professionals as an event which would devastate her and raise the risk of suicide.

But after she was left to live with an adult friend Sally King, insufficient checks were carried out on her and no guidance and advice was given on how to look after the schoolgirl.

Mr Williams told the inquest in Stourport that social services should have put plans in place for the teenager to be supervised at all times.

He said: "Had arrangements been put in place for Dana to be constantly supervised by Sally King, for the urgent involvement of Child and Adolescent Mental Health Services and daily visits by social workers, Dana would not have had the opportunity of taking her life in the way that she did and it is more than likely than not that she would have survived they crisis."

In coming to his judgement, Mr Williams said Dana's human rights had been breached under article two of the act.

He said from March 2011, Dana was at a 'real and immediate risk of death by suicide', and this was known by those who cared for her.

He said: "I find that it would have been the simplest measures, and well within the power of the local authority, to have asked Sally King not to let Dana out of her sight and to arrange for visits on a daily basis by professionals."

He added: "In my judgement these simple steps would have avoided Dana's death on March 3 and therefore I consider that Dana's article two rights were breached."

In conclusion, he said Dana, who killed herself with a dog lead purchased from a pet shop, hanged herself with 'clear and deliberate intention of ending her own life'.

He added: "Her death was contributed to by a failure to have in place adequate measures to protect her from a known, present and continuing risk that she would kill herself.

"I find that Dana was extremely vulnerable, the nature of risk was completed act of suicide; the magnitude of the risk was very great indeed and that the protective measures were almost non-existent."

Mr Williams said that there had been 'serious, systematic failings' , which led to social workers and carers having an 'imperfect understanding' of her needs.

In a statement, following the inquest, Dana Baker's family including parents Patricia and Trevor said: "We are pleased that the last three weeks of evidence and today's conclusion from the coroner have finally answered some of the questions we have had about Dana's last few days and hours.

"Whilst we note the criticisms he had made of the care provided to Dana, this will of course do nothing to bring her back.

"Throughout this inquest,we have heard evidence showing that on the part of agencies charged with Dana's care there were a series of failings and communication, lack of consistent care and poor relationships between professionals whose focused should have been on working together to protect Dana.

"Those failures led to the risk Dana posed to herself not being properly understood, this meant that when Dana lost the support system on which she had come to rely she sadly made the decision to take her own life.

"We have heard very upsetting evidence about how in the last few hours Dana was asking for help. That help was not forthcoming, we will never know whether the outcome could have been different if Dana got the support she as asking for."

The statement added: "We sincerely hope that changes will be made as a result of Dana's death untimely and tragic death."

Following Dana's death, Worcestershire Safeguarding Children Board carried out a serious case review to identify where improvements can be made.

The review has found that the work of agencies looking after Dana could have been 'joined up better', in particular in assessing and managing the risk the schoolgirl posed to herself.

Councillor Liz Eyre, Worcestershire County Council's cabinet member for children and

families, said: "There is no doubt, that Dana always had social care and other professionals around her who cared for her.

"At the time of her death there were a significant number of professionals involved with her care.

"However, we see that we are the lead, co-ordinating agency with corporate parenting responsibility. Where we could have done better, we have made changes at the earliest opportunity."