'Quiet, sensitive' teenager found dead in Bognor graveyard 'wasn't rated as high risk'

Jake Harding, who lived with his mum and three younger sisters in Bookers Close, was found dead at St Mary Magdalene graveyard in October 2019.

An inquest, at Crawley Coroner's Court today (January 22), heard how Jake developed anxiety at a young age, which eventually led to depression.

He had seen a speech therapist after becoming 'frustrated and embarrassed' about his stammer.

According to his mum, Laura, Jake 'wanted to engage' with the sessions but often couldn't.

"Some days, he couldn't face it," she said. "He had not been well, not been sleeping and had been to see a GP."

Jake was prescribed medication but this was limited due to his age.

In 2018, at the age of 17, Jake was referred to the Child and Adolescent Mental Health Services (CAMHS) and had meetings with mental health professional Filomena Venton in Stockbridge Road, Chichester.

Ms Venton said Jake spoke about his suicidal thoughts but he said he wouldn't act on them, 'as he didn't want to upset his family'.

Ms Venton added that her concerns about Jake were eased, as he spoke about his plans for the future, including becoming a tree surgeon.

She said: "We felt he was low risk. We work with a lot of young people who are high risk. Their presentation is different.

"He had future plans. He was absolutely over the moon that he had been accepted at Brinsbury [College]. He had applied to do a tree surgeon course. He had lots of positive things going on.

"If someone wants to die, they can't talk about future plans. That was reassuring.

"If we felt he was at immediate risk, we could have put in urgent health services in place."

Jake 'would change' when talking about his hobbies, Ms Venton said.

She added: "He was telling me about making YouTube videos. He didn't have a huge following but he would light up talking about that. His body language was different.

"The plan was to continue following up and review [the situation]. I was going to see him on a regular basis. We don't just leave young people feeling like that."

However, Jake stopped turning up to sessions and did not respond to requests to join a cognitive processing therapy (CPT) group.

In what Ms Venton admitted was a mistake, she only attempted to make contact with the family over the phone, instead of following policy by posting a letter.

Ms Venton also admitted to not putting her conversations with Jake into writing, adding: "I usually do that, I don't know why I didn't."

Jake was eventually discharged by CAMHS but, again, the family were not informed with a letter.

There had also been no conversations about transferring Jake, who had turned 18, to adult mental health services.

Ms Venton added: "The letter was not done and I regret that and I'm sorry.

"I am really sorry to the parents about what's happened."

Jo Shepherd, West Sussex Coastal fertility manager for CAMHS, led an investigation and incident review after Jake's death.

Giving evidence, Ms Shepherd acknowledged a 'lack of formal' documentation or written communication, including a discharge letter.

"That wasn't thought about enough," she said. "There was a lack of transitional planning to adult services. Those conversations didn't happen.

"CAMHS is a service under incredible pressure. We have compassionate clinicians and I have a human understanding.

"We are introducing recovery days. All clinicians will have one day a month to recover, and there will be no appointments.

"They will use this time to look at their work load and scrutinise cases. This has gone down well."

Ms Shepherd said 'awful, tragic situations', such as Jake's death, 'affect our teams and clinicians', adding: "It makes people think carefully.

"He came across as fairly low risk but there were procedures that needed to be followed. He was ambivalent with his engagement and that's very normal when people's mental health is up and down."

Jake's parents were separated but were both a 'big part of his life'.

In her prepared statement, Jake's mum Laura said: "Jake was a quiet, sensitive lad. He was very clever.

"He was very caring of his three younger sisters. He liked camping and walks on the Downs."

Describing his son as a 'lovely child', who was very fond of animals, Jake's dad, Ian, said lessons need to be learned.

He said: "I understand the strain on [mental health] services, which are overworked and underfunded.

"I don't want to put blame on anyone but there's things that could have been done better."

The coroner, Sarah Clarke, ruled a conclusion of suicide, expressing her sincere condolences to Jake's family.

Anyone affected by the issues raised in this article, or anyone needing support, can contact the Samaritans by calling 116 123 for free, or visit the website at www.samaritans.org.