The inquest into the death of 16 year-old Daniel Sewell-French concluded that “clear and significant failings” contributed to his death. Daniel’s mother was represented by Tom Stoate of Garden Court Chambers.
Danny died in his bedroom on 2 October 2016 at a children’s home run by Blackburn with Darwen Borough Council in Lancashire. The inquest heard that on the evening of 1 October 2016 at 7pm Danny had returned to the home very intoxicated. Whilst back at the home he consumed more alcohol, morphine and buprenorphine. He was checked briefly by staff during the early hours of Sunday 2 October 2016, and was found dead later that morning at around 11:30am.
The Senior Coroner for Blackburn, Hyndburn and Ribble Valley, Michael Singleton, concluded that clear and significant failures in safeguarding procedures contributed to Danny’s death. He found that:
- No adequate steps were taken to ensure that Danny was not in possession of drugs and alcohol when he returned to the home on the evening of 1 October 2016;
- Only a “cursory search” of Danny’s room was undertaken which was a “clear and significant failure” to identify that he was in possession of drugs and alcohol, not only for safeguarding Danny but also for the safeguarding of all of the other children in the home; and
- Insufficient observations were in place for Danny, meaning that the opportunity was lost to administer naloxone (a drug used to treat potential drug overdose) earlier.
The Senior Coroner also criticised the home for not acknowledging or adhering to a risk assessment put in place for the management of Danny’s care, which had been reviewed by management at the home just two days prior to his death.
A Serious Case Review into Danny’s death is currently ongoing.
Danny’s mother, Barbara said;
“The inquest found that Danny was badly let down by significant failings in his care. Danny was vulnerable and we believed he would be kept safe and looked after. I am now looking forward to the Serious Case Review making changes to the safeguarding systems in place at the home, so that lessons can be learned from Danny’s tragic death and no more families are put in this position.”
Kelly Darlington, Solicitor for Danny’s mother said;
“This is an extremely tragic case involving a vulnerable child. The Coroner identified that there were serious issues in Danny’s care that contributed to his death. It is hoped that lessons can be learned from this tragedy to ensure that other children are safeguarded in the future.”