On 29 November 2014 Assistant Chief Constable Paul Netherton tweeted: “We have a 16-year-old girl suffering from mental health issues held in police custody. There are no beds available in the uk! #unacceptable”
The tweet sparked outrage and national media coverage. But mental health professionals and charities weren’t surprised. Mental health services have always been underfunded and, since the start of austerity cutbacks in 2010, the situation has got worse. NHS spending on children and adolescent mental health services (CAMHS) in England has fallen by more than 6 per cent in real terms since 2010. Because of bed shortages, mentally ill children may be treated hundreds of miles from home.
The disjointed and patchy services for children and young adults means many are dealt with punitively rather than medically. They find themselves in prison or held in custody, rather than in hospital or receiving therapy in the community. Once young people are in the criminal justice system, it’s even harder to get them mental health support.
Policy and practice varies in different places. Some youth services stop at 16. Adult mental health services start at 18. What happens to those young people who fall through the gap?
Kesia Leatherbarrow was a lively child with a mischievous smile. Sometimes her enthusiasm landed her in trouble.
Like the time she spotted a mouse one morning on her paper round, scooped it up her sleeve, and headed off to school. Later that morning her mother, Martina, a science teacher and department head, received a phone call: Kesia was in hospital with a swollen face because of an allergic reaction to a mouse bite.
Martina smiles and hugs her arms tightly around her small frame. She has the same thick chestnut brown hair and alert brown eyes as her daughter. “Kesia liked all animals. Do you know Elmyra, the cartoon? She’s a cartoon character that loves animals and squeezes them so much that they can’t breathe, that’s what Kesia was like.”
When Kesia was well, mum and daughter had a happy relationship.Kesia would lug her accordion to their bathroom and play while Martina relaxed in the bathtub.
Kesia played well. She performed at charity events and competitions, was principle accordionist in a children’s band, enjoyed being the centre of attention. But in the bathroom with her mum was her favourite place to play.
“I was only 17 when I had Kesia, just before my 18th birthday. It was a surprise,” says Martina. “But there was never any doubt that I was going to do everything I could to make her life better and to give her a good life.”
Martina and Matt, Kesia’s stepfather, an assistant head teacher, were devoted to their only child. By the time she was four Kesia could read and recite the periodic table. As she got older Kesia poured her energy into everything; scuba diving, holidays abroad. “She loved excitement. She loved theme parks and roller coasters. She was just so much fun.”
Between the ages of 12 and 14 Kesia turned inward. Her energy became rage and would often erupt. Trivial misdemeanours, fiddling with her ear stretcher or chatting in class, would escalate into Kesia screaming and shouting at her teachers.
She started cutting her arms and legs. “Kesia was extremely academic and very able,” says Matt, “but didn’t quite fit the mould of what’s expected of all children. She struggled with that. The school were punitive in their response.
“There is so much you can do for a young person, however all they ever did with Kesia was to warn and punish, warn and punish, warn and punish.”
Martina and Matt needed help. They tried their local Children and Adolescent Mental Health Service, but staff refused to meet them face to face and dismissed them over the phone more than once.
The thresholds for accessing children’s mental health services are high. They were told, time and again, that Kesia’s problems were behavioural and not a mental health concern.
But Kesia was more than just an angry teenager. Something was deeply wrong. Even now Martina and Matt struggle to define Kesia’s illness. It wasn’t a quiet or episodic illness, Kesia’s anger was constant, intense, raw. It came in violent waves that would devastate her family.
“Round the clock for years firefighting,” says Matt. “Kesia’s not going to get her GCSEs, Kesia’s not going to sit her exams. Kesia’s not going to get her college placement.”
These practical considerations had to take second place to what was happening inside Kesia’s head. Day to day, hour to hour they tried to understand, manage and soothe Kesia’s mental illness. She knew there was something wrong, something wrong with her brain, Martina says quietly, “and no one could tell her what.”
When she was 15, Kesia was permanently excluded from school for possessing a small amount of cannabis. Her parents knew they would lose an appeal.
“You know the behaviour was wrong, it was a damning case. We couldn’t have dealt with it,” says Matt.
Any pastoral support from the school for Kesia should have come before things deteriorated, they reasoned; it was too late for that. They accepted the school’s advice that Kesia could sit her GCSE exams at a special short stay school. “They guaranteed that they would enter her for her exams,” says Martina, still angry. “They didn’t enter her for any of them. I was so angry at the time. Kesia was upset.”
Early on in the summer of 2013, Kesia, now 17, stopped eating.
Her body weight dropped to six stones (she was five foot four). She crumpled and seemed to wither. Where she once screamed and lashed out, now she only whispered.
When Kesia’s illness manifested in rage and ‘misbehaviour’, Martina and Matt had found it impossible to get help for her. Now that she was quiet, docile, broken, help came, but briefly.
A local mental health crisis hospital accepted that Kesia was ill and gave her a bed for five weeks. She was put on anti-depressants (20mg of sertraline, later increased to 50mg) and given counselling. “She began eating again and started putting on weight. She was absolutely loving, too,” says Martina.
In the two weeks after she left hospital outreach and crisis teams met with Kesia three times, but when she started missing appointments they discharged her completely. Once again the family was alone.
A few months later in October, one Friday afternoon, Martina phoned Kesia.
“Kesia was at home and I was at work. She was supposed to be having her boyfriend come round to the house and I rang her to make sure everything was OK, only to be confronted with Kesia screaming down the phone.
“I couldn’t get any sense out of her and became incredibly worried. I rang an ambulance and explained to them she had just come out of hospital and I was really worried about her. Then I left work and went home.”
Outside the house was a police car and an ambulance van. Martina assumed the police car was there because of her call. By this time Kesia had left the house. After a while, there being no patient, the ambulance left. But the police officers stayed outside the house. Martina left to look for Kesia.
When she arrived back at the house an hour or so later, the police were sitting in the front room. On the sofa opposite sat Kesia, ignoring them. The police were questioning her about a razor blade. Kesia turned the TV on and put the volume on full blast. Unable to elicit a response from her daughter through the noise, Martina switched off the electricity at the mains. “At which point Kesia went upstairs to her bedroom and shut the door. The police went backwards and forwards to their car, then came back in and said, ‘We’re going to take her.’”
Martina pleaded with the officers, spreading her arms and using her body to block the staircase. “I told the police all about her mental health, that she was vulnerable, that she’d been self-harming, that she was on anti-depressants. They pushed me out of the way.”
The two officers dragged Kesia, all six stone of her, kicking and screaming down the stairs. Her skirt rode up to her chest in the struggle. They pushed her into the police car. Martina blamed herself. “I just broke down, everything after that is a bit of a blur.”
Matt came home that night to find his wife unable to speak. He would spend the next 36 hours trying to get Kesia a full mental health assessment. Meanwhile Kesia was in a police cell, tearing out clumps of her hair and threatening suicide.
Later Martina discovered that Kesia’s boyfriend’s parents had called the police because she was had a razor blade and was threatening to harm herself. That’s why the police were at house that night. Kesia was charged with assaulting a police officer because she’d kicked one of them during her arrest.
Frantic and desperate, Matt called “everyone you are supposed to ring when you have a crisis”. Someone from the hospital that had looked after Kesia that summer told him, “This is probably what she needs, she needs to understand there are consequences to her behaviour.” Matt laughs, two years on he is still incredulous: “Judicial treatment would do Kesia good. This is what I got told.”
At the police station Matt begged the custody and liaison officer, who, he says “had some sort of mental health qualification”, to carry out a full medical health assessment so that on release Kesia could be referred for mental health treatment. “I said to her, what exactly are you waiting for? Are you waiting for something really serious to happen before you take some action? She is mentally unwell. She caused my wife to have a breakdown, she needs help.”
“She completely ignored me and didn’t take heed of what I was saying at all. And we know that five weeks later…”
One day after her release Kesia went to a motorway bridge and threatened to jump. The police were called again; they arrived and took her to her grandmother’s house. They didn’t call Matt or Martina.
Later that day Kesia went to stay with her biological dad in Tameside, Manchester. Martina and Matt weren’t keen but decided that a break from their home in Chorley might do her some good. Martina says, “We totally ran out of options. Crisis didn’t want to know. Outreach didn’t want to know. The police couldn’t do anything. Nobody was willing to help us. That was it.”
Following Kesia’s arrest in October 2013, Lancashire Constabulary created a file which said she was ‘at risk’ and likely to self-harm. This was passed on to other agencies including Lancashire Children’s Services. When Kesia moved to Tameside, Lancashire passed the file on to Tameside Children’s Services. When it came to assessing what to do with her, Tameside decided against conducting a social work assessment and instead referred her to Tameside Children and Adolescent Mental Health Services, which at that time had a waiting list of 12 weeks.
The hospital did not contact Kesia nor did they book her in for a mental health assessment.
Kesia stayed in Tameside for about four weeks. Though children’s services held files about her past behaviour, self-harm and a suicide attempt, Kesia was given little or no support from children’s mental health services or any social services. Left alone to cope with her turmoil, she smoked cannabis and spent a lot of time with a new, much-older boyfriend. In four weeks she came into contact with Greater Manchester Police eight times, twice when she phoned to report alleged instances of domestic violence by her boyfriend.
Things came to a head on 30 November 2013. Kesia was arrested in Manchester for breaking a window and possessing about £10 worth of cannabis. She was held in a cell for two nights, that’s 12 hours longer than the last time. Again, she screamed, cried, smashed her head against the walls, pulled her hair, and threatened to jump off a motorway bridge. At one point she sat naked in a pool of her own urine.
The custody officers were concerned, but kept her in the cell. Twice, they called for medical help. A nurse came, but wasn’t told about Kesia’s suicide threat. The nurse’s medical assessment was later described as “incomplete and … well short of being a meaningful assessment”.
It took more than 12 hours before Kesia was provided with an “appropriate adult”, a volunteer social worker from Tameside social services. She wasn’t aware of Kesia’s suicide threat nor was she told about the nurse’s visits. Her assessment of Kesia should have been sent to social services, but Tameside never received the document.
Kesia’s prisoner escort form noted her history of depression and a past suicide attempt, but not her latest threat.
The police reported Kesia’s threat to jump off a motorway bridge to the Crown Prosecution Service and indicated concern about what she might do on release. But at Kesia’s hearing on the 2nd of December, three days after her arrest, her solicitor, the youth offender team, and the judges remained in the dark about Kesia’s threat and the full extent of her behaviour in the cells.
Martina discovered all this more than a year later. “Do you know what the police’s defence was for not doing anything? People say that all the time. That is what they said. People say that all the time because they don’t want to be in the cells.
“They were presented with a girl who was absolutely…totally…she would have been going out of her mind. For three days she would have been going out of her mind. They did nothing for her. She would have been covered in self-harm scars. All over her. They were all up her arms, all down her legs. She’ll have been saying I am going to kill myself and they did nothing. They made it worse by locking her up for three days for breaking a window.”
Martina was at work when Kesia’s dad rang. She stepped out into the school corridor to answer the call. She’s hung herself,he said. Kesia is dead. Martina collapsed onto the floor. A colleague scooped her up and took her into an empty classroom. The world caved in, she wanted to die. For months afterwards she was numb. When feeling returned it was a dull sense that she could never enjoy anything again.
It took another year and the inquest into Kesia’s death, before Martina and Matt could finally piece together the last days of their daughter’s life. For six weeks the couple listened, numb and in shock, as dozens of witnesses, from youth offending teams, children’s social services, the police, crisis mental health, gave evidence.
“It was horrendous,” says Martina. “The worst thing about it was seeing people sit up there and try to justify the lack of care that they’d given to Kesia. That was the worst part because we know what happened. One of the custody sergeants in court described her, in front of me, as feral. He said that in front of me. She was so badly behaved, she was feral.”
Just before her release, Kesia attended a bail hearing at the magistrates’ court. A guard from the security company GEOAMEY says she was the most distressed he had ever seen any detainee in 15 years of working. Kesia’s erratic behaviour continued throughout her bail hearing. The court released Kesia on the condition that she stayed at her father’s house. She was due back at the youth court the next day.
What did Kesia do following her release from custody on 2nd December? Nobody knows. Kesia left the court alone. She was found dead the next morning.
A catalogue of failures
Lawyers working with the charity INQUEST represented Kesia’s family at the inquest. INQUEST say that if the magistrates court had been given information about Kesia’s suicide threats in the cells, the judge could have made it a condition of her bail that she be assessed by a mental health professional.
Deborah Coles, co-director for INQUEST, said: “This is a deeply shocking story of a vulnerable child failed by all the agencies that should have been there to protect her. Kesia did not slip through the net. Her risk factors should have been obvious to anyone who got into contact with her and yet neither an individual nor an agency made it their job to make sure that she was safe. What happened to Kesia within the last weeks of her life is a shocking catalogue of failures both in relation to diverting young women from the criminal justice system and in relation to her journey into custody, mental health and policing, uses of private contractors and the treatment of children in detention.”
Where inquest evidence points to failings that might cause further deaths, a coroner is obliged to write a “prevention of future deaths” report and send it to any organisations that have responsibility for the circumstances. (Such reports used to be known as ‘Rule 43 reports’).
Joanne Kearsley, the coroner investigating Kesia’s death, ruled that in the weeks leading up to her death, the police and various social services missed opportunities and failed to protect her. She sent the report to three government ministers, Greater Manchester Police, Tameside council, Lancashire county council, Pennine Care NHS Foundation Trust, MEDACS healthcare (it was one of their nurses who assessed Kesia in custody), the Crown Prosecution Service, and the National Police Chiefs’ Council.
Joe Lawton, a bright teenager with plans to go to university and travel, took his own life two days after being arrested and held in custody for drinking driving in August 2012 when he was 17. His parents found out about the arrest only after their son’s death. Edward Thornber, a 17-year-old lacrosse star, killed himself in September 2011 after being arrested and charged with possessing cannabis worth 50p.
The families came together to campaign to change the law that allowed 17 year olds to be treated as adults in custody. They raised more than 50,000 signatures on an online petition. Working alongside the charity Just for Kids Law they supported a Judicial Review. (It was led by barristers at Doughty Street Chambers, with support from the Howard League and Coram Children’s Legal Centre.) In April 2013 the High Court ruled unlawful the Home Secretary’s failure to change the law “so as to distinguish between the treatment of an adult detainee” and someone under 18.
So, in 2013 when Kesia was arrested and held in custody, it was not lawful to treat her as an adult. Someone from her family should have been called. “They never contacted me. Nothing, not a thing,” says Martina. “They didn’t tell anyone when they bailed her. Even though she said I am going to kill myself.”
Joe’s and Edward’s families were horrified by Kesia’s death. “They were under the impression that they’d managed to change the law to protect children. They thought they had won,” says Martina.
In the two years since Kesia died, her parents have campaigned to try to make sure that what happened to their daughter won’t happen to other children. Just for Kids Law sent Martina and Matt a note of condolence and support after Kesia’s funeral. That helped. Together they campaigned for a change in the Police and Criminal Evidence Act 1984 (PACE) so that the term “arrested juvenile” included those under 18, rather than just children aged 12 to 16.
Martina set up a change.org petition: 30,000 people signed. The petition was part of popular social media campaign #stillachildat17. They opened their lives up to journalists, gave press conferences. Trips to London carrying photos of Kesia to meet with MPs, Lords, senior police officers. Martina and Matt walked 190 miles across England in 12 days raising more £1,500 for Survivors of Bereavement by Suicide. Recently the couple appeared in a poster campaign to save the Human Rights Act.
In November last year Martina and Matt watched from the House of Lords gallery as the proposed changes to the Act were accepted. Fiona Bawdon, a journalist who worked on the Just for Kids Law #stillachildat17 campaign wrote: “It was an incredibly emotional moment. All the more so when the earl went on to talk about Kesia, Eddie and Joe – and also about Martina and Matt.”
Francis Michael Hare, the Earl of Listowel, who tabled the amendment, said: “Great tribute must go to Martina and Matt Baines, the mother and stepfather of Kesia Leatherbarrow. Despite their terrible and at times overwhelming grief, they threw themselves into campaigning for what they think of as Kesia’s law. Without the commitment of these extraordinary parents in their time of enormous loss, I do not think that the changes would have been made today.”
This meant the world to Martina and Matt. It’s the campaign, support from lawyers, journalist, politicians and members of the public that has helped them find meaning in their loss. Martina says: “The most important thing for us is that nobody else has to suffer the way Kesia suffered. And the way we suffer now. Kesia will make a difference, she is making a difference. She is leaving a legacy.”
This piece was commissioned and first published by Shine A Light at openDemocracy.
Response to criticism
openDemocracy contacted agencies that came into contact with Kesia for comment.
Warren Larkin, Clinical Director for the Children and Families network at Lancashire Care NHS Foundation Trust said:
“The circumstances of this case are extremely tragic and our thoughts and condolences are with Kesia’s friends and family. As a Trust we take any learning following a Serious Case Review or our own internal reviews very seriously. We are committed to providing safe and appropriate care and we recognise the importance of providing age appropriate mental health services for 16-17 year olds. It is acknowledged in the Future In Mind report published recently that the transition between children, young people’s and adult services is an area that needs particular attention nationally. As part of our commitment to transforming children and young people’s emotional health and wellbeing services we will be looking to review and strengthen this area and will continue to work with our partner organisations, young people and their families to do so in a way that meets their needs.”
Sara Barnes, Directorate Manager for Child and Adolescent Mental Health Services (CAMHS) at Pennine Care, said:
“Our sympathies remain with the family of Kesia Leatherbarrow and Pennine Care has fully cooperated with investigations into her care and treatment. Practices have been improved to help the reduce the risk of such events happening in the future, particularly with ensuring a smooth transfer of service users from out of the area, gathering written information from other agencies and ensuring referrers properly understand what support CAMHS can provide.
“All referrals to CAMHS are triaged based on need; urgent referrals are seen more quickly and routine referrals are seen for a first assessment within 12 weeks, which is in line with national targets. Locally in Tameside, routine referrals are typically seen within eight weeks. The referral for Kesia was triaged and assessed as routine and an appointment was allocated within seven weeks.”
A Tameside council spokesperson said:
“Tameside’s Children’s Safeguarding Board undertook a joint Serious Case Review with Lancashire Safeguarding Children Board to establish what lessons we could learn about how agencies dealt with Kesia before her death. The conclusion of this, together with the Coroner’s report have led to a number of service improvements being implemented both in the council and partner agencies.”
Assistant Chief Constable Garry Shewan of Greater Manchester Police said:
“First and foremost, our thoughts are with the family of Kesia Leatherbarrow, who have understandably been left devastated by her tragic death and I have personally passed on my condolences.
“We accept as an organisation there were shortcomings in the care that we provided to Kesia and following her death we introduced new care processes for those in police custody for whom we have concerns of self-harm, in the hope such a tragedy will never occur again.”