Erskine bridge suicides
inquiry criticises care home
teenagers Niamh Lafferty and Georgia Rowe, who jumped into river Clyde,
could have been prevented, inquiry says
A sheriff's inquiry into the double suicide of two vulnerable teenage girls has severely criticised the care home where they lived for failing to protect them from harm.
A fatal accident inquiry (FAI) said the deaths of Niamh Lafferty and Georgia Rowe in 2009 could have been prevented had the Good Shepherd centre near Erskine, west of Glasgow, taken the right care of the girls, both of whom were known to be at risk of suicide and self-harm.
The girls, aged 15 and 14, died after jumping hand in hand into the river Clyde from the Erskine bridge after absconding from the Good Shepherd in Bishopton one Sunday evening in early October 2009, walking the short distance from the home to the bridge.
After hearing 65 days of evidence, Sheriff Ruth Anderson QC found that the home had wrongly put the girls in an unlocked, self-contained flat on the ground floor, next to an unalarmed fire exit, and failed to have the right number of staff on duty that evening.
Among a series of breaches of rules and procedures, it emerged there should have been four staff on site but there were only two on duty and, at times, just one staff member was in the building.
The inquiry discovered the fire alarm had been cut off on the orders of a Good Shepherd head of service, Sandy Cunningham, because the girls were repeatedly using the door to leave the building and the alarm was disturbing staff.
The exit had no CCTV coverage, so staff had no way of tracking girls who were absconding. The sheriff said: "The sole means of monitoring the whereabouts of each of the girls was staff awareness. There was no additional security. If a girl wished to leave the open unit without permission, she could do so."
The girls, both from troubled and disrupted family backgrounds, had a history of self-harm, attempted suicide and serious drug and alcohol abuse, which included heroin use and binge drinking. Anderson ruled they should have been accommodated in a more secure unit on the first floor, of the care home.
Making a series of recommendations to tighten up on the care of vulnerable children, the sheriff said "reasonable precautions" could have prevented their deaths.
"I would wish once more to express my sympathy to the families of Niamh and Georgia and to put on record how grateful I am for the way in which those who attended the inquiry conducted themselves throughout, both in the giving of evidence and in the way they conducted themselves during the many days of evidence, much of which must have been distressing for them all. They behaved with dignity and restraint throughout," the sheriff said.
She said the two central failures by the Good Shepherd were heavily influenced by the failures of all the authorities involved in the girls' care to properly carry out detailed and thorough risk assessments for them, and put in place proper management systems.
In addition, the Good Shepherd did not have sufficiently robust policies on children who absconded, staff failed to communicate properly and the home had wrongly played down the bullying of Rowe by another girl in the unit.
The sheriff ruled: "No standalone risk assessment was ever done on either Niamh or Georgia by their placing authorities nor by any of the residential establishments in which they were placed.
"Had such an assessment been carried out, regularly updated, and accompanied each girl to the various establishments in which she was placed, then management and staff charged with their health and safety would have had a readily accessible and comprehensive document as a valuable tool to assist them in their responsibilities and to alert them to the risks which pertained, whether those were in relation to absconding, self-harm or suicide."
Lafferty, whose legal name was Niamh Frances Bysouth but was commonly known as Niamh or Neve Lafferty, was from Helensburgh on the Firth of Clyde, while Rowe, legally known as Terrie Faye Oliver, had strong Scottish roots but had come to the care home from Hull.
Anderson formally noted expert recommendations to her inquiry by Prof Stephen Platt, a specialist in suicides from the Centre for Population Health Sciences at Edinburgh University, on improving suicide prevention and care by Scottish councils.
Platt told the inquiry he did not believe either girl could have been successfully stopped from attempting or committing suicide. He said: "If forced to give a one-word answer to the question, 'Were the deaths of [Rowe] and [Lafferty] preventable?' the most honest answer has to be 'probably not'."
Platt told the FAI that councils should have clear guidelines on managing looked-after children at risk of suicide, including detailed procedures for any child at risk of or threatening suicide, while care home staff "should have a sound understanding of the risk of self-harm and suicide among their clients".
In a statement, the managers of the Good Shepherd's remaining facility, a secure unit, said the open unit where the girls were based had been closed in June 2010 and was now demolished, largely because of the girls suicides.
They said lessons would be learned following the FAI report and the girls deaths "was the saddest and most traumatic event" in the unit's history.
It added: "No one who worked with Georgia and Niamh was unaffected by this tragedy which was utterly unprecedented, both in the professional lives of staff and in the history of the institution.
"The impossibility of predicting such an event emerged in the evidence, but at the same time, weaknesses in the handling of the girls' circumstances were identified, for which the board expresses its profound sorrow."
1 May 2012