Charlotte Baron: ‘More could and should have been done’ to prevent the death of troubled teenager

Date published: 12 September 2017

‘More could and should have been done’ to prevent the death of troubled teenager, Charlotte Baron, a damning report has concluded.

Charlotte, 14, was known to social services and was being seen by a mental health practitioner when she was found hanged at her home on Heights Lane, Rochdale, on 20 February 2016. A coroner later ruled her cause of death as 'misadventure'.

Published on Monday (11 September) by Rochdale Borough Safeguarding Children’s Board, the Serious Case Review (SCR) determined Charlotte was failed by those she relied on when she needed them the most: her mother, social workers and mental health worker.

The review says Charlotte’s voice went unheard, despite her ‘telling several professionals how she was feeling’ and ‘how the experiencing of parenting affected her’.

It goes on to say: “There are many examples of Charlotte telling people how she was feeling and what she needed. She told professionals she could not cope within her home environment and this led her to take an overdose. Her attempts to find alternative living solutions were misinterpreted as her not conforming, rather than her only means of achieving a degree of control over the issues she found very difficult to cope with.”

Family life

A ‘bright and capable' pupil at St Cuthbert's High School, Charlotte had experienced a troubled upbringing, with an alcoholic mother and her father, who later served a prison sentence for domestic violence.

In the first seven years of her life, 10 incidents of domestic violence occurred that prompted a police response. She also had a disrupted childhood, having moved house around ’27 times’.

The review says Charlotte had been self-harming since Year 7 after experiencing unhappiness at home, which had no heating or electricity, and lacked food.

She had expressed a desire to move out of her family home, and had begun staying with friends and other family members wanting to ‘be somewhere where she feels looked after.’ She ‘didn’t want her life to be like this any more’.

Charlotte experienced a difficult relationship with her mum, who believed her self-harm and suicide attempts were ‘attention-seeking’. The review adds this ‘re-enforced her sense of worthlessness and hopelessness’.

Charlotte was also worried ‘a great deal about her mother’s physical health related to high levels of drinking’ and about ‘the impact of this on her mother’s emotional availability’.

The reluctance of her mother to engage with agencies was ‘apparent’ throughout this case, and she failed to attend meetings.

Previous attempts

Charlotte had previously attempted to take her own life on two previous occasions.

In September 2015, Charlotte was admitted to Urgent Care having overdosed on painkillers.

The CAMHS assessment conducted at the time showed Charlotte ‘felt she could not discuss her worries with her mother, believing she would become annoyed’. She was identified as high risk.

In December that year, Charlotte was taken to hospital after being found in the park intoxicated. The A&E consultant was aware Charlotte had previously attempted overdose and was open to the CAMHS service.

The hospital informed Children’s Social Care EDT, CAMHS and a referral was made to an alcohol nurse linked to young people. Charlotte was discharged the next day without further CAMHS assessment.


The report confirmed that Charlotte’s father was not approached at any time, adding that excluding men is ‘commonly identified’ in Serious Case Reviews.

It went on to say: “It is striking that Charlotte’s father was neither informed nor consulted about the position of Charlotte. It is suggested this is because Charlotte did not introduce him as a source of potential support. From the professionals’ perspective, it is possible they were influenced by the knowledge that he had been convicted and served a prison sentence.”

“Mark had a right to known of the concerns about his children and Charlotte gave the social worker a contact number for him; whether he could offer support in terms of building resilience should have been explored. The failure to include men and in particular an absent father in assessments of families is almost a cliché and the need to do so in order to understand a child’s whole circumstances must be continually re-enforced.”

Mark, whose circumstances did not allow for Charlotte to live with him at the time, commented: “Charlotte hated how she lived at home: she had nothing. She asked so many people for help and they didn’t help her. I didn’t know that Charlotte had tried before. They didn’t tell me. They said they left me a voicemail the first time but I have no recollection of it.”

“There were so many failures. They all said they could and should have done more to help her. Their statements were proved wrong. It doesn’t seem right. They made out they saw Charlotte more than they did.

“I feel so let down; I thought people would have been sacked over this. How many more have they lied about?”

Social Services

Charlotte’s social worker was a practitioner of just one years’ experience and ‘needed consistent management support’. In spite of this, and the realisation that her mother ‘would undoubtedly have been a very difficult client’ to work with, ‘the management oversight of this case’ was poor and there was ‘a gross naivety’ in social services’ belief that she would address her drinking problem.

There is a sense that ‘practitioners over empathised’ with Charlotte's mother, who saw the illness of her mother as an ‘excusable reason’ for drinking, which had a ‘profound impact’ on Charlotte.

She was neither advised of, or introduced to, organisations that provide specific emotional support to children who are affected by alcohol, such as Al-a-Teen or Nacoa (national association for children of alcoholics).

It was noted within the report as ‘striking’ that the social worker’s view of Charlotte’s death was ‘presented as somewhat out of step with the reality of this case’. She described Charlotte’s death as ‘a shock’ because she ‘believed that the multi-agency plan was making progress’.

There was also a lack of availability of minutes from the Child in Need meetings, which ‘is the responsibility for Children’s Social Care as the lead agency to ensure this is achieved’. One meeting, was described by her mother's alcohol practitioner ‘as very informal without access to a written plan and no minutes being made available’.

Charlotte was also advised to stay at her own home rather than friends and family, in order to settle’, reducing and ‘dismissing’ one of her ‘coping strategies that decreased risk’.

There was also ‘no record within Children’s Social Care’ of a police referral made in summer 2015 after police attended the home following an argument between Charlotte and her mother.

Mental Health

Following her first suicide attempt, Charlotte also started seeing a mental health practitioner from Pennine Care NHS Trust’s Child and Adolescent Mental Health Service (CAMHS).

The report claims the mental health worker was ‘extremely concerned’ about Charlotte and ‘expressed frustration’ that ‘something should have been done’.

Despite her concerns, she was not present at any of the three ‘Child in Need’ meetings, held for Charlotte’s case.

The report also found the standard of record keeping in CAMHS fell ‘short of agency standards’ and ‘causing concern that this deficit had not been identified through usual management approaches and audits’.

The relationship between the two key agencies was also criticised for not developing as a multi-agency partnership, who did not share plans to help Charlotte. Communication was limited to ‘approximately five telephone calls or emails and joint visit in December’.

The report outlined both the social worker and CAMHS practitioner were at times ‘struggling with how to respond to the issues this case presented.’


The Serious Case Review found that both Child and Mental Health Strategy service and Children’s Social Care ‘accepted more could and should have been done to support and listen’ to Charlotte.

The panel recommended referring all children at medium or high risk of harm through self-harm or suicide directly to Children’s Social Care, ‘who will then coordinate a multi-agency professionals meeting.’

Authorities’ response

Jane Booth, Chairwoman of the Rochdale Borough Safeguarding Children Board, said: “On behalf of the Rochdale Borough Safeguarding Children Board and its partner agencies I wish to extend our condolences to [Charlotte Baron’s] family and friends.

“The Serious Case review we have published clearly identifies the lessons that needed to be learned to improve practice when working with vulnerable teenagers and their families.

“The Board will continue to monitor agency action plans to ensure these improvements are made.”

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