Bradford Council ordered to act after girl's death in 2019

A Prevention of Future Death Report sent to the local authority in relation to the death of 15-year-old Leah Barber was published on August 4.

It outlined that assistant coroner at Bradford Coroners’ Court, Raja Mahmood, ruled the teenager’s death on June 3, 2019, had come about by suicide.

The inquest into Leah’s death concluded on April 28 this year, after first beginning on June 12, 2019.

The Regulation 28 report said Leah suffered “a range of mental health pressures in the last 18 months of her life” and this “fluctuated” in terms of nature and severity.

The report was issued to Bradford Council following the inquest, due to concerns there could be future deaths because of a “clear disconnect in the involvement of the various Council departments” with Leah.

The report, made by Mr Mahmood, said: “During the course of the investigation my inquiries revealed matters giving rise to concern.

“In my opinion there is a risk that future deaths could occur unless action is taken.

“In the circumstances it is my statutory duty to report to you.”

Evidence was heard from a number of parties at the inquest, including two schools Leah attended, Bradford Children’s Social Services, the TRACKS Education team (at Bradford Council), the SCIL Team and the Council’s SEND Team, said the report.

Bradford City Hall (Image: Newsquest)

This revealed that a single person or department did not have an overview of the local authority’s involvement in relation to Leah prior to her death.

But of “greater concern” was that this remained after each of those Council departments involved were notified of Leah’s death.

The report said it appeared Bradford Council did not have a system or process in place to have an overview of deaths where they were previously involved with that individual.

It added: “In the apparent absence of such oversight Bradford Council would not be able to learn lessons from such cases (or even know if there were lessons to be learned).

“The absence of such a single point of oversight as was apparent in Leah's case, contributes to the risk that future deaths could occur unless action is taken.”

Mr Mahmood made it clear that the individuals from various Bradford Council teams who provided evidence to the court, in written statements and from two people who attended and spoke in person, did not cause this disconnect.

He also said that the hearing did not identify any actions or omissions on the part of the individuals or teams within the Council that "more than minimally, negligibly, or trivially contributed to Leah’s death". 

Every other organisation that had contact with the coroners' service in relation to the case, including the police and local mental health trust, was able to provide an overview or analysis of their involvement with Leah prior to her death, according to the report.

They also outlined, where appropriate, the lessons they had learned as a result of this.

The Telegraph & Argus contacted Bradford Council for a comment.

Marium Haque, director of children’s services, said: “It’s difficult for anyone hearing the story of Leah’s death not to be moved by it.

“It has been hugely upsetting for all those affected by it, our thoughts are with her family and friends.

“We fully accept the coroner's report and will respond to him so we can assure him that we’ve already taken action to address his concerns.

“A huge amount of work has happened since then to establish better system-wide practices.

“Suicide prevention training is available to practitioners and there are arrangements in place to provide oversight on children and young people at risk.”

Bradford Council is under duty to respond to the report within 56 days, namely by September 15 this year.

This response must contain details of action taken or proposed to be taken, setting out the timetable for action.

If no action is proposed, the local authority must explain the reasoning behind this.