Jennifer Chalkley: Coroner issues Prevention of Future Deaths Report after death of young autistic girl

The Senior Coroner for Woking, Richard Travers, has issued a Prevention of Future Deaths Report, to the Department of Education and Surrey County Council, following the Inquest into the death of Jennifer ‘Jen’ Chalkley.

Jen was just 17 years old when she took her own life on 12 October 2021, at her home in Surrey. An Inquest investigation into Jen’s death has found that multiple failures on the part of Surrey and Borders’ Child and Adolescent Mental Health Services (CAMHS) and Surrey County Council contributed to Jen’s death.

 

The Coroner has raised two key concerns in his report:

 

• The first concern relates to a misunderstanding by schools and colleges in the level of resources they need to spend on a young person with special needs, before they can apply for an Education, Health and Care Plan. The Coroner noted that this is delaying or preventing applications for statutory assessments being made in some cases. It thereby acts as a barrier to ensuring all children and young people with additional needs are receiving effective support as soon as possible.

• Secondly, the Coroner is concerned that there is not a national system in place to require and facilitate the guaranteed transfer of safeguarding information in advance of a child or young person starting a new school or college at the start of a new term or academic year, and that this exposes a suicidal child or young person to additional and avoidable risk.

 

The Coroner believes that action should be taken to prevent future deaths by addressing the concerns set out in the report. He believes the Department of Education and Surrey County Council have the power to take such action.

 

Both organisations are required to respond to the Coroner’s letter, in writing, within 56 days, by 9 December 2024.

 

Jen’s mother, Sharren Bridges, said:

 

“Our educational system is constantly failing young, neurodivergent people. There are too many complex and often-misunderstood barriers and processes in place to ensure children and young people receive the support they need to thrive at school. Parents, who try time and time again to explain their children’s needs, and what can sometimes easily be put in place to support them, do not feel listened to.

While I am grateful that the Senior Coroner has found this to be the case, it will only provide reassurance if the central government, along with Surrey County Council, take action to significantly improve their systems, putting the needs of neurodivergent children and young people at the heart of the process. This could drastically reduce the growing number of children and young people making attempts on their lives or completing suicide before they are old enough to leave school.

The failings of Surrey County Council and the education system irreparably shattered our lives the day Jen died.”

 

The Prevention of Future Deaths report can be read here.

 

Ms Bridges was represented at the Inquest by Daniel Cooper and Patrick Dunne of Imran Khan and Partners, and Maya Sikand KC of Doughty Street Chambers.