Sam Gould: 'Systemic failure' in death of girl, 16

A coroner has said "systemic weaknesses and failings" in communication between healthcare agencies probably caused the death of a 16-year-old.

Sam Gould took her own life with an overdose of prescription drugs in Fulbourn, Cambridgeshire in September 2018.

Coroner Nicholas Moss QC said there were "shortcomings" in her case.

An inquest for Chris Gould, Sam's twin sister, who died in January 2019, will take place next month.

The inquest at Huntingdon Town Hall heard that the twins had "loving parents", and that Sam was "an accomplished horse rider" who was described as "funny, kind, sassy and irreverent".

Sam had borderline personality disorder, which Mr Moss said in his findings at the end of the inquest was the "main cause of her death".

The assistant coroner for Cambridgeshire and Peterborough told the hearing that in 2016 Chris said she and Sam "had been seriously sexually abused from a young age and into their teenage years".

The court was told the criminal investigation was closed as Sam and Chris did not wish to provide an evidential account in a video interview.

Clinicians assessed Sam's borderline personality disorder "to be related to allegations of prolonged sexual abuse in her earlier childhood", said Mr Moss.

"The disorder caused a persistent, but unpredictable and fluctuating risk of serious deliberate self-harm and suicide," he added.

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The inquest heard that Sam's parents Ian Gould and Jane Cannon would manage and dispense her medication.

Mr Moss said that on 17 August 2018 her mother found a "stockpile" of Sam's medication in Chris' room.

On 30 August at an appointment with her consultant psychiatrist, Sam denied stockpiling the medication, saying that she had simply stopped taking it and it was not working.

The coroner said Sam had been angry that the psychiatrist had discussed the medication find with Mrs Cannon, and the psychiatrist "would optimally have given more weight to Sam's reaction".

The doctor said in evidence she "wished she had... given Sam the weekend to discuss it with her parents and got Sam to come back" for a prescription which she was given at the appointment.

When Sam went to the pharmacy on 1 September, she found that other medications were "waiting for her", said the coroner.

Mr Moss found that on 29 August her GP surgery Cornford House "should not have prescribed" one of the drugs used in Sam's overdose without further checks after a doctor was "partially misled" by a "confusing" letter.

Sam was found dead on 2 September from an overdose.

The coroner said: "The psychiatrist did not know that older prescriptions were on hold at the surgery.

"There was a systemic weakness and failing in the lack of a protocol for child and adolescent mental health service [CAMHS] and the GP service to communicate with local pharmacies concerning 16-18 year-old patients with mental health conditions who were at risk of deliberate overdose.

"Sam was therefore able to pick up older prescriptions on 1 September without challenge.

"It was those medications that were fatal in the combined amounts Sam ingested on the night of 1-2 September.

"These matters combined were a probable cause of the death in that they gave Sam a means to end her life on the night of 1-2 September."

The coroner also found "shortcomings in communication and joint-working" between her school, the local authority and CAMHS following two "significant" events linked to the school in February 2018.

In a statement, Sam's school, Bottisham Village College, run by Anglian Learning, said it "extended their heartfelt sympathy to Sam's family and friends".

The statement said it was a "tragic and complex case" and the college "is always seeking to enhance its well-established strategies and processes".

"At Bottisham Village College - in addition to the many developments which have been supported by mental health organisations - we will continue to reflect upon and adapt our practices further as necessary as a direct consequence of Sam's death."

Cornford House declined to comment when contacted by the BBC.

The Cambridgeshire and Peterborough Safeguarding Children Partnership Board said it had commissioned a serious case review and would await its findings.

"In the past two years since Sam's death, all agencies have strengthened guidance and collective response to children who have been the victims of child sexual abuse and young people who are suffering from mental health issues," it added.

The Cambridgeshire and Peterborough NHS Foundation Trust said: "We offer our sincere condolences to the family and friends of Samantha Gould, and we will look to continue to work with all partner organisations in light of the findings made by the coroner."

At the end of the inquest, Bridget Dolan QC, the barrister for Sam's parents, said they thanked the coroner for his "detailed consideration" of the case.

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