THERE were some individual failings in efforts to get psychiatric support for a teenage boy who went on to take his own life at a Pembrokeshire school, an inquest has found.

The inquest into the death of 14-year-old Derek Brundrett, who was found hanged at Pembroke School on December 12, 2013, concluded on Tuesday, February 19.

Returning a narrative verdict, Assistant Coroner Paul Bennett, found: "That Derek Brundrett took his own life and intended to do so in circumstances where, despite efforts to refer him for psychiatric support there was a failure to do so."

Mr Bennett found there was a failure to refer by a social worker, a failure by a GP to provide extra information when referrals in 2012 and 2013 were declined and a failure to provide the relevant information on the appropriate referral form of a Looked After Child."

No systemic failures were found.

Derek's death was in the context that he had been returned to foster care and was concerned about a return to the Pupil Referral Unit.

Derek's actions were not considered to be a cry for help but rather a deliberate attempt at self-harm, the Coroner's report stated.

Detailing the events of December 12, 2013, Mr Bennett said that, around 12.36pm Derek was seen on CCTV leaving the school for a nearby wooded area, known as the ‘circle,’ and was later found hanged by a friend some 40 minutes later.

Mr Bennett told the inquest Derek “had set about a deliberate act of self-harm,” having gone to the ‘circle,’ not visible from the outside, during normal lesson time.

Friends had noticed a deterioration in his mood and behaviour, the inquest had heard.

Mr Bennett described previous evidence of risk taking, including climbing on the school roof, but said the December 12 situation was different as it was not in the full view of others.

“In my view he had no intention that anyone should find him in time to save him, only that he would be found, probably by his friends. This was, in my opinion, a deliberate act with an intention to take his own life.”

Speaking after the inquest, Derek’s mum, Kristina Wray said: “It obviously wasn’t the verdict I was hoping to get. From the opening day of Derek’s inquest, I have held hope and faith that justice would be found at last. Through a very prolonged process I’ve sat in hope.

“Today, the coroner found that Pembrokeshire County Council failed Derek, in that they failed to get him the help he needed.

“The coroner found this may well have resulted in a different outcome for Derek.

“The coroner also found that the GPs failed to provide further information when asked to do so by SCAMHS [Specialist Child and Adolescent Mental Health Service].

“I sincerely hope that lessons will be learned, so that other children will not be failed in the same way.

“I look forward to receiving an apology from the council, who could’ve saved my boy’s life.

“It now just has been put down to suicide when it could’ve been manslaughter from the agencies. They failed me and they failed my son.”

She said she was considering a legal challenge, adding: “They had an opportunity to stand up and help me right from the beginning.”

A Pembrokeshire County Council spokesman said: “The death of a child is a profound loss and all the professionals involved in this tragedy feel great sympathy for Derek and his family and friends. We would like to repeat our sincere condolences to them at this time.

“Derek’s loss is deeply felt by those individuals who had formed close and caring relationships with him.

“We would like to thank the Coroner for his thorough investigation and consideration of the case.

“We will, of course, reflect upon all of the issues that have been raised during the Inquest, and consider what lessons can be learned with a view to continuing to ensure the safeguarding and well-being of all children and young persons served by Pembrokeshire County Council.”

Pembroke Dock county councillor Joshua Beynon, a pupil at Pembroke School at the time, said: “I, myself, was a pupil of Pembroke School when Derek took his life in 2013 and I remember being in school that day. I will never forget it and my sympathies go out to Derek's family and friends on what must be a difficult day.”

Cllr Beynon submitted an urgent question to Pembrokeshire County Council at its February 21 meeting.
Cllr Beynon asked: “Can Pembrokeshire county Council outline what steps they have, and will be, taking to ensure that they are doing everything to avoid another tragedy like this?”
Cllr Tessa Hodgson, cabinet member for social services, said the coroner's report was 35 pages, which was to be closely examined and detailed actions will be drawn up.
"We are considering the issues arising from that decision and what actions can be taken," she added.
She welcomed the request of Cllr Beynon that, once this work was carried out, the report go to scrutiny committee for further discussion.
Cllr Hodgson outlined the mental health work currently carried out in Pembrokehire's schools including access to a education psychologist, specialised nurses, an emotional health and well being panel and training offered to all staff on suicide prevention.
"The death of a child is a profound loss," said Cllr Hodgson as she sent her sincere condolences to Derek's family and all that knew him.