Last week I was in court in Bradford for the first part of Myles Scriven’s inquest and was therefore unable to report from Nonita’s inquest at North London Coroners Court, but I still wanted to share it with you.

Nonita adored animals and was thinking of training to become a vet. She was very creative, she made artwork and bracelets and had started to sell them online. She loved Hello Kitty, My Little Pony and watching Disney movies.

Nonita was autistic and had a history of mental ill-health, disordered eating and self-harm which had resulted in hospitalisation. Nonita had told professionals that she had been abused in early childhood.

In May 2022, Nonita became a looked after child, with the London Borough of Barnet becoming her “corporate parent”. At the time Nonita was just 16 and had been stopped from jumping off a bridge by a member of the public. Nonita was hospitalised at that time, and on a further three occasions, in the following 19 months before her death on 28 December 2023.

Nonita completed her GCSEs in a specialist school for children with mental health difficulties, achieving 6 good grades. Despite attending a special school, Nonita had no EHCP (Education, Health and Care Plan) and she was not in education or training following her GCSEs.

Nonita had clearly communicated her intent to take her own life, on more than one occasion. She told a doctor in her first hospital admission how she would do it. She requested that she go to live with foster carers on her discharge from hospital, but none were available. A year before her death, in December 2022, Nonita disclosed again that she would take her life when she turned 18 as she would not be supervised as closely as she was at the time.

In the last 8 months of Nonita’s life the following happened:

May 2023

Barnet Council moved Nonita to The Singhing Tree in Harrow, a privately-run supported accommodation service, meant for older children in care deemed ready to prepare for independent living. At that time, this kind of accommodation was unregulated.

The Operations Director of the home had no social work qualification, had no training in autism and had last attended safeguarding training in 2021 or 2022. [Their website refers to Asperges Syndrome, which show’s you how little they understand autism, not just the typo but the inappropriate use of a term that was removed from the DSM over a decade ago, not least due to Hans Aspergers eugenic collaborations with the Nazis].

Staff from the supported accommodation told Nonita’s inquest had they known about Nonita’s previously expressed intention to die on train tracks, this would have made them question the suitability of their accommodation, given its close location to train tracks.

They also gave evidence they were unaware of Nonita’s 2022 statement that she would take her own life when she turned 18. The Operations Director added he had not been given, or read any of, Nonita’s care plans, despite a legal duty for this to be shared by the council.

June 2023

Nonita told the owner of The Singhing Tree she was concerned about being seen at a nearby fenced railway station [she had already disclosed she would die on train tracks]. The station was close to a local park Nonita spent a lot of time in and close to The Singhing Tree.

July 2023

Barnet Council were told by The Singhing Tree in a monthly report, and the council noted, Nonita’s conversation about the nearby train station.

The same month Nonita was hospitalised for six days following a serious self-harm incident.

Neither this, nor Nonita’s fears about being seen at the nearby railway station were discussed among professionals in subsequent statutory reviews of her welfare.

September 2023

Nonita secured a college place to study for a Level 3 Animal Management qualification, starting in early September. However, this place was rescinded once the college received information about the support Nonita would need to complete her studies.

October 2023

A meeting of all the professionals involved in Nonita’s life took place. After it Barnet Council’s Head of Corporate Parenting recorded:

“Nonita has shared that she is not turning 18 and that she still wants to be a child. She identifies as a child; she watches children’s television and has toys that she takes out”.

12 October Nonita is discharged from CAMHS (Child and Adolescent Mental Health Services). No arrangements were put in place for Nonita’s ongoing mental health support. The discharge letter sent to her GP included the following:

“It is important to consider if the level of support is reduced too quicky or if she is unprepared in future for natural life transitions, self-harm will return as this is her baseline behaviours when emotionally or sensorily overwhelmed”. 

19 October Nonita is finally referred to Barnet Adult Social Care. It is not clear whether Nonita was ever told this referral had been made. There had been no social care assessment before Nonita died in December.

At the end of that month Nonita’s relationship with her art therapist came to an end. This was a significant relationship for Nonita.

November 2023

[By now Nonita has nothing to do, she’s been rejected by the college she’d hoped to study at (an all too familiar experience for autistic and learning disabled young people) and I imagine she was feeling overwhelmed, rejected and lost].

An educational psychologist conducted an EHCP assessment and found Nonita “feeling stressed, bored and sad”.

December 2023

4 December Nonita’s final Child-in-Care statutory review takes place

11 December Nonita’s volunteer Independent Visitor from Action for Children, Katharine Bryson (a retired teacher with nearly four decades’ experience of working with children) raised written safeguarding concerns about Nonita’s lack of enrolment in education and training and general unhappiness

13 December Nonita’s 18th birthday

20 December, a week after her birthday, Nonita attends a “leaving care dinner” at the Leaving Care Office. This left Nonita feeling “overwhelmed”.

25 December Nonita spent Christmas Day at her supported accommodation, The Singhing Tree

28 December Nonita died on railway tracks, close to where she was living, shortly after leaving her accommodation.

[How alone and desperate Nonita must have felt. By the time she ended her life she had repeatedly told multiple adults of how she would do so. Her requests to live with foster carers weren’t accommodated. This young, vulnerable autistic person was left, lost, with nothing meaningful in her life. Her mental health support had ended, her art therapy had ended, the college had rejected her. She’d asked her social worker to continue visiting, she’d been explicit that she did not want CAMHS support to end.

With the exception of her Independent Visitor, Katharine, none of the many adults and professionals in her life appear to have taken her concerns, clearly communicated to them, seriously. The serious safeguarding concerns Katharine had raised, and that Nonita empathically wanted to be passed on, were not communicated to Barnet Council by Action for Children until January 2024, by which time Nonita had died].

Coroner’s findings

Coroner Peter Murphy found CAMHS left Nonita without any specialist mental health support during a critical period of transition. This was done before any referral was made to adult mental health services, despite Nonita making clear she did not want support to end and asking her specialist social worker to visit her again after their final planned visit.

The Coroner found Nonita formed the intention to take her own life, and the following probably made a more than minimal contribution to Nonita’s death: 

1. The absence of coordinated transition from secondary school to college as a looked after child, resulting in Nonita not being in education for the four months leading to her 18th birthday and lacking a sense of purpose – both of which were triggers for her suicidal ideation
2. The absence of a coordinated transition out of CAMHS as a highly vulnerable looked after child, leaving Nonita without any specialist mental health support from 13 December 2023 as she approached a known and dangerous crossroads in her life.  
3. The absence of a coordinated transition out of children’s social care, resulting in several key decisions for Nonita’s future being unresolved or unconfirmed by the time of her 18^th birthday. This included funding for her residential placement, referral to adult social care, her education and immigration status. Uncertainty and isolation were known to cause Nonita distress and anxiety.  
4. The absence of coordinated information-sharing between the various agencies involved in Nonita’s care which inhibited effective assessment and management of the risk Nonita posed to her life as she transitioned into adulthood and out of care. 

The coroner will be issuing a Prevention of Future Deaths report in relation to these issues.

Legal representation

Article 39 and Inquest were granted Interested Person Status in Nonita’s inquest. They believe this to be the first time a non-governmental organisation has been granted IP status at a UK inquest, despite not knowing or being in contact with Nonita before her death. Her Independent Visitor, Katharine Bryson raised her concerns with Article 39 following Nonita’s death. Ciara Bartlam of Garden Court North Chambers and Serena Fasso and Blodina Rakovica of Wilsons Solicitors LLP represented Article 39 and Inquest pro bono at Nonita’s inquest.

Other interested persons at Nonita’s inquest were London Borough of Barnet, North London NHS Foundation Trust, The Singhing Tree and Action for Children.

I have approached London Borough of Barnet for comment.