Teen's suicide could have been avoided - coroner

The death of an “amazing” 17-year-old who took her own life could have been avoided if support had been provided in a “timely manner”, Surrey’s coroner says.

An inquest into the death of Jen Bridges-Chalkley concluded on Wednesday.

Jen took her own life at her mother’s Bookham home in October 2021.

The organisations concerned said they would learn from the findings and make changes.

Jen was referred to CAMHS three times, for the first time in 2015, but Richard Travers, senior coroner for Surrey, said: “For much of the time between May 2018 and June 2020, she was on a waiting list for therapy from the psychology team and was awaiting assessment.”

Mr Travers said there was “pressure on staff to refer patients” to services for those in need of support rather than specialist services, and to discharge from the community team.

The coroner concluded the children and adolescent mental health service (CAMHS) had failed “to properly to assess, diagnose and treat Jen, in order to manage her conditions and minimise her risk of suicide”.

The coroner said he was satisfied that, had specialist input been provided “in a timely manner”, the teenager’s final crisis would “probably have been avoided or managed, such as to avoid her death”.

Jen’s mother, Sharren Bridges, said agencies needed to “listen with eyes and ears” to parents, young people and schools who were requesting support.

She said: “You shouldn't have to jump through so many hoops and fight so many battles.

“I'm just a lowly mum, trying to do the best for my child.”

Ms Bridges described her daughter as "an amazing human being".

“She was my everything. She’s playful, she's funny, she's intelligent. To me, she was perfect.”

Graham Wareham, chief executive of Surrey and Borders Partnership NHS Foundation Trust, said the organisation remained committed to making improvements in support for young people and their families.

He added: "I am deeply saddened by the tragic death of Jennifer Chalkley in October 2021, and I have written to her family to express my heartfelt thoughts and condolences and to apologise for our shortcomings."

Surrey County Council’s special educational needs department also failed to ensure Jen’s education and health care plan reflected her needs, the coroner said.

Rachael Wardell, the council’s executive director for children, families and lifelong learning, said the authority would “work at pace” to learn from the findings and make necessary changes “as quickly as possible”.

She said: “We take these findings extremely seriously and sincerely apologise for any part our services played in Jennifer’s tragic death and the distress of all those who love her.”

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