A coroner in Cornwall will be issuing a report to the Youth Justice Board for England and Wales after finding one of its self-assessment forms contributed to the death of a teenager from Redruth, an inquest heard last week.

HM Assistant Coroner Guy Davies has said he will be asking for a section 28 report from the Youth Justice Board for England and Wales, which aim to prevent future deaths, after finding that a section in a self-assessment form which it issued contributed to "a moment of crisis."

The 16-year-old, who The Packet has chosen not to identify out of respect for their family, died by suicide in September 2020.

At the inquest into the teenager's death, the court heard how the 16-year-old had been known to police and social services after being involved with a number of incidents, including a group assault in Redruth and several instances of being reported missing, that had resulted in an anti-social behaviour investigation.

After a police investigation, the teen was issued with a stage one anti-social behaviour warning in March of 2020, however, it was noted that during the incident the teenager had appeared to be 'almost a bystander.'

Support services were offered, however, they were declined.

During the inquest, PC Andy Filkins told of how the Covid-19 pandemic, as well as the availability of an appropriate adult, had caused delays in proceedings which meant that the teen was not issued with a Youth Conditional Caution (YCC) until six months after the initial offence.


During this time, the teen's mother told the inquest how she felt the teenager had managed to turn their behaviour around and that they were now "doing family chores and taking part in movie nights," adding that they "rarely went out anymore."

Youth Offending Services representative, Kate Wilson, advised that a self-assessment form had been sent to the teen's home address via the post, and that there was no specific guidance as to whether the form is sent via the post or explained and discussed in-person.

She said: "There's no standard practice, especially during Covid.
"There was nothing to suggest that it would be inappropriate to deal with it in this way on this occasion."

While giving evidence, the teen's mother described the teen as "a well person physically and took pride in their appearance," and told the court how she felt the location ban had left them feeling "isolated," adding that they had been "visibly upset" due to seemingly being brought back to a place from which they had moved on. 

She said: "I do feel this form has contributed to their death as they had never searched for suicide or self-harm, it's not a good form to just send to a youth who is confused."

While giving his verdict, Assistant Coroner Guy Davies said it was his conclusion that the teenager had intentionally taken their own life in "an impulsive act in a moment of crisis" and could not have been anticipated by the family or support services.

"In regards to the self-assessment form, there are circumstances causing a further risk to life" adding that he would be issuing a "Regulation 28 report to the National Youth Justice Board in relation to that form."

  • If you've been affected by suicide or are struggling with your own mental health, there is help available.

Papyrus Hopeline UK is a confidential support and advice service for children and young people under the age of 35 who are experiencing thoughts of suicide as well as anyone concerned that a young person could be thinking about suicide: Call: 0800 068 41 41, text: 07860 039 967, email: pat@papyrus-uk.org

Samaritans is a registered charity aimed at providing emotional support to anyone in emotional distress, struggling to cope, or at risk of suicide throughout the United Kingdom and Ireland.

Call: 116123 or email: jo@samaritans.org.uk

SOS-Silence of Suicide is a national service for anyone who needs emotional support, understanding, compassion & kindness.

Call: 0300 1020 505 or email: support@sossilenceofsuicide.org

Shout: Shout is a free, confidential, anonymous service for anyone in the UK. It won’t appear on your phone bill. To start a conversation, text the word 'SHOUT' to 85258.

Mind: Get short and longer term support in a mental health crisis by visiting www.mind.org.uk

If you feel like your life is at risk right now or you need urgent medical help call 999 and ask for an ambulance or go straight to A&E if you can.