Northern Irish Courts - Miscellaneous

Neutral Citation No: [2021] NICoroner 10     Judgment: approved by the Court for handing down (subject to editorial corrections)*

Ref:    [2021] NICoroner 10                                     Delivered:  17/09/2021

 

 

Coroner’s Inquest Findings

Johnny Declan Shields

CSNI Ref: D-03355-2017

Coroner Mrs A-L Toal

 

 (1)  The deceased, Johnny Declan Shields was born on 12 March 2003, and resided at 11 Creggan Road, Mountnorris, Armagh with his parents and younger sibling.

 (2)  On 6 November 2017 in the early hours of the morning, Mrs Shields noticed her son was missing from the house and she and her husband began to look for him in the garage and surrounding outbuildings to no avail. When his father reversed his van out to drive around to try and find his son, he saw him located unresponsive in the back of the van and later found his nail gun on the floor of the van. Despite attempts at resuscitation Johnny was sadly pronounced dead at Daisy Hill Hospital later that morning. He had shot himself in the head with his father’s nail gun.

 (3)  Declan and Kate Shields, Johnny’s parents gave evidence to the inquest. They described how on Monday 6 November 2017 at approximately 5.30am they got up after Mrs Shields was awoken by a noise and noticed that Johnny’s bedroom door was open but he was not in his room. Mr Shields noticed the handle on the kitchen window was open but the window pushed closed and went to check the shed and garage. He thought he would take a drive up the road in his van to see if Johnny was walking on the road. When he got into his van and started reversing he noticed the back light in the rear was on and in the rear seat he saw Johnny lying flat, face down. He got him out of the van to check for a pulse then carried him inside while his wife phoned the ambulance. Mrs Shields said she noticed he had blood on his forehead. Mr Shields continued CPR, together with his brother, until the ambulance arrived and Johnny was taken to hospital where resuscitation was stopped after it became clear there was no point continuing.

 (4)  They described how all the doors in the house had been locked the previous night, as had the van and Mr Shields’ toolbox and he had taken the keys to bed as Johnny had tried to carry out the same act a number of times previously in the preceding six months and they had been doing this ever since. Mr Shields said at times his nail gun would have been kept in the locked van. He said he believed Johnny had opened the locked van earlier in the day and would have had to have known to keep the door ajar so the automatic lock would not operate. They both made clear Johnny was not looking forward to returning to school after the holidays and that he hated school, but Mr Shields said although Johnny always said he hated school he had never given a specific reason for this. They described how the family had been for a walk earlier in the day and that Johnny had left the walk early to return home but they did not think this was unusual. In the week preceding his death Johnny had been working with his father, which he loved. Although he had recently stopped taking his medication (prescribed for his depression and agitation) he had restarted this again prior to his death and neither noticed anything to indicate Johnny was going to do what he did that morning and described him as being in good form in the week leading up to his death. They also confirmed that while there had been a lot of arguments over the preceding months about Johnny’s use of computers, there had been none that week. They explained in their evidence that in the few years prior to Johnny’s death he had experienced the loss of a teacher and parish priest, both of whom he had been close to and that they had also had a number of family bereavements including grandparents of Johnny.

 (5)  They described how Johnny had self-harmed over the previous six months and had attempted suicide on four previous occasions since May 2017. In three of the suicide attempts he had the nail gun. There had been an earlier incident in or around early May 2017 when he was found with his father’s nail gun in his bedroom, although at that time his father said they had not realised he was contemplating harm to himself as he would often have his father’s tools and would have fixed them on occasion. On one occasion he had taken a litre of vodka from the house and drank it and threatened to use the nail gun on himself. On another occasion he ran off with his father’s nail gun and his father had to chase him into a field to get it off him. On a further occasion on the night of 1 June/ early hours of 2 June 2017 there was a much more serious and what his father described as a determined attempt, he had gone into the garage when his parents were sleeping, taken the nail gun, found the nail cartridges his father had hidden after the previous attempt and had texted his parents to say they could find his body in the garage, fully expecting himself to be dead when they did so. On that occasion the nail gun had misfired and his parents, who had read the text rushed to the garage and rescued the situation. Then on 12 September 2017, he had attempted to overdose on medication which resulted in an overnight stay in hospital. They said that prior to May 2017 there had never been any suicide attempts although on one occasion in 2014/2015 he had said to them in the context of being bullied that “he didn’t want to be here anymore”.

 (6)  They described how after the attempt on 1 June they had contacted their GP Dr Quinn the following morning who saw them that day, but that despite the GP seeking an urgent assessment for Johnny, they were told by Child Adolescent Mental Health Services (CAMHS) that an assessment was not available to them and that Johnny wouldn’t be admitted, that if they needed help or were concerned they could take him to A&E as a place of safety and that he would be seen in the next week by CAMHS. No-one apart from Dr Quinn spoke to Johnny that day and no one gave them any advice what to do with a suicidal child other than they could take him to A&E. They described their feelings of hopelessness and frustration at this horrendous situation and that Johnny, whom they had primed for the possibility of hospital admission, was disappointed that he had asked for help and was not hospitalised.

 (7)  Mrs Shields explained how she, after being told that Johnny wouldn’t be seen until Wednesday 7 June, had contacted Dr Cassidy on 5 June and asked her to see him to which Dr Cassidy agreed and saw him that day and thereafter he had one hour per week with Dr Cassidy at CAMHS and was prescribed medication which they felt helped. They said they did not inform the school about these suicide attempts at any stage because Johnny was adamant he did not want them to and that they were acting on the advice of Dr Cassidy not to tell the school or their wider family in line with Johnny’s wishes.

 (8)  Mrs Shields went on to explain that in August of 2017 Johnny had been assessed for Autism Spectrum Disorder (ASD) on the recommendation of Dr Cassidy and was subsequently diagnosed with ASD. In her view he was accepting of this diagnosis and although he did not want the school to know about it initially, he had eventually agreed to them being told. She said they had received information about CAMHS Connect, which assists children with ASD, after his diagnosis in September 2017, but the first course he was able to be booked on to was not scheduled until December 2017 and the first course they as parents were able to be booked on to was in January 2018.

 (9)  As regards his hatred of school, Mrs Shields described how he had had two close friends in primary school with whom he would have spent a lot of time with both in and out of school but they had not attended Abbey Grammar. She explained that at the start of Johnny’s first year she had concerns in the first few weeks after Johnny told her he had made no friends and was walking around school on his own, however she called his form teacher Mrs Lane to discuss it who told her she had also noticed this and that she would help him.

(10)  Around Christmas time she said Johnny befriended a boy “X” but then this friendship had turned sour. She described how at this time, around February 2015, Johnny’s mood and behaviour at home changed and he went from being a happy young boy to being argumentative so she took him to the GP. It was a few months after this, in or around late April-early May 2015 that Johnny told them that X had come at him in class with a shield and brush and she said over the next few weeks she began to keep a record of what Johnny was telling her about the many more incidences of bullying by X so they could go to the school with some evidence.

(11)  She said she had initially wanted Johnny to tell the teachers himself about the bullying but when Johnny had approached his form teacher Mrs Lane she had been dismissive of him for wringing his hands. She then phoned Mrs Lane to ask for a meeting and at that meeting told her about the bullying and gave her a list of 20 bullying acts, many of which were physical or verbally taunting in nature, that X had been doing to her son. She said that during the meeting she was told that the issues would be dealt with, that X would not be seated beside Johnny in class and that if the situation didn’t improve X could be moved out of the class the following academic year. She said that Mrs Lane also apologised to Johnny for being dismissive of him and she felt that matters would be dealt with after that meeting.

(12)  After this meeting she said she knew X had been given a detention and a warning but the bullying of Johnny by X continued after her meeting with Mrs Lane. A few days after this meeting X made a rude gesture to her outside school, so she said she alerted the school and met with Johnny’s Year Head and the result was that X was suspended. She explained there had then been a further incident in Year 8 where X had brought a hurley stick into school at a time when no games were taking place and had threatened to use this on Johnny, so she again had to contact the school and ask for the stick to be removed. She described how Johnny was also offered counselling at various times, of which she said she would have been supportive, but Mr Shields described how Johnny was very reluctant to see the school counsellor as Johnny had said the rest of the school would know about it as they always knew when someone was being taken out of class to go see the counsellor.

(13)  She said Johnny had returned to school in Year 9 on the understanding that X would be in a different class but this turned out not to be the case. She said X continued to bully Johnny and brought two other boys that Johnny had become friendly with into it, so she contacted the school again about this and the failure to move X out of Johnny’s class. The outcome of that call was that she was told that X would be dealt with and the other boys spoken to. Johnny later told her the result was one hour of detention which frustrated him as he felt the teachers didn’t care. She also had to contact the school to advise that the two boys had been sat beside each other in class again and was told that this would be dealt with. She said it was her view that Mrs Lane was very dismissive of her concerns that anything was still happening and would only continue to suggest counselling for Johnny but would never say why he needed counselling.

(14)  After these incidents in early Year 9 she said Johnny hardly ever mentioned what was happening at school any more as he was frustrated that she had told the school in the first place and it had not made a difference. She said while Johnny never again said he was being bullied she did note he would come home on occasion from school with his lunchbox broken or his work taken off him, although Johnny refused to say what was going on and she confirmed in her evidence she never spoke to the school about this. She said that up until the start of May/June 2017 she did feel that although Johnny didn’t like school it seemed he was getting on ok and she knew he sometimes met a group of other boys in the music room over lunch. She accepted that in the 16 sessions Johnny had had with Dr Cassidy that ongoing bullying had not been raised by Johnny as an ongoing stressor but did say returning to school was a worry. She confirmed the school never contacted her to express any concerns regarding Johnny and nothing was ever raised at parent/teacher meetings and that after his death that she was told by someone that he was being bullied after the last incident she had been aware of in Year 9.

(15)  She described how she then had no contact with the school until after Johnny had started refusing to go to school in or around the latter part of Year 10 and she struggled at times to get him to attend. She explained how in June 2017 she phoned Mrs Lane about the difficulty in getting him to school and his lack of work on subjects he was not intending to keep on. She said it was then Mrs Lane told her that Johnny had not been engaging with other pupils at school and needed to see a counsellor. Mrs Shields said when she asked Mrs Lane if she knew why Johnny hated school so much and felt so demoralised she said she didn’t know but gave her the impression she thought it was down to problems at home. She said that it was always her who had to contact the school about any issues with Johnny such as the bullying and that the school never phoned her to discuss any concerns they had about him not engaging with other pupils or that he was socially isolated over the three years previous, nor did they discuss with her anything they were doing with regards to Johnny.

(16)  In the term beginning with late August/September 2017, just prior to his death, Johnny’s attendance was very poor from the start and both Mrs Shields and her husband recounted how they struggled daily getting him to attend school. She confirmed it was at this time she raised with the school both Johnny’s attendance at CAMHS and also his assessment for ASD and subsequent diagnosis. She confirmed she did not raise the issue of the suicide attempts or any concerns regarding bullying at that time. She said it was her view that while the school seemed to be encouraging her to send Johnny to school and sent home work for him to do, they did not do enough to help him with the issues he had nor did they investigate the reasons for his behaviour and poor attendance.  She did however say that she had no criticism of how they dealt with the ASD diagnosis and Johnny’s IEP which was in train at the time of his death.

(17)  Colin Harte, paramedic, had his evidence admitted under Rule 17. He described how when they as ambulance personnel attended they carried out CPR until transfer at Daisy Hill Hospital at 6.20am. Throughout his attendance there were no signs of life.

(18)  Dr Waheed, who had his evidence admitted under Rule 17 confirmed that on arrival at Daisy Hill hospital at 6.32am Johnny had no heartbeat, CPR and resuscitation attempts were continued at the hospital however this was unsuccessful and life was pronounced extinct at 6.50am.

(19)  Dr Johnson, Assistant State Pathologist carried out the post-mortem and his evidence was admitted under Rule 17. He confirmed death was the result of a penetrating head injury. A nail gun, found at the scene, had been placed against his head and discharged. The nail had passed through his scalp and skull and into the brain. This would have caused immediate unconsciousness and death shortly thereafter. The wound was found to be consistent with being self-inflicted. There was no evidence of drugs of abuse or alcohol, only sertraline which he was prescribed and amiodarone which would have been given during resuscitation attempts.

(20)  Margaret Lane, Johnny’s form teacher Years 8-10, gave evidence to the inquest. She described how Johnny joined her form class in September 2014 and she was his form teacher for three years. As a form class teacher, she explained, she would see the form class for 15 minutes each morning and deal with administrative issues such as reading notices, checking homework diaries were signed by parents each week and was also there to deal with any pastoral care issues of her students. She said she would have spoken to each boy at least once a week and kept notes of her interactions with parents and any issues.

(21)  She noted in the first week of Year 8 that Johnny was not making friends so she said she actively encouraged other quiet pupils in the class to form friendships with Johnny who was reluctant to engage. She did not relay her concerns about Johnny not settling in as she said it was early in the year. She said she received a phone call from the school nurse on 11 September 2014 who advised that she was a relative of Johnny’s and that his mother had concerns he was not settling. She said she, together with the Year Tutor, monitored the situation and she tried on occasion to encourage him to make friends and she suggested counselling to Johnny but his uptake of the offer was poor. When asked was there a stigma attached to the counsellor, she said she was aware it was an issue. She said she also encouraged him to join clubs such as the STEM club and tried to praise his IT skills in front of the class. Mrs Shields phoned her in early November regarding her concerns about Johnny settling in and she said Mrs Shields was also supportive of counselling. However, as Johnny was reluctant to engage with the counsellor, they respected his decision and did not push the matter.

(22)  She explained in her evidence how throughout this time rather than contacting Mrs Shields regarding her concerns about Johnny and what actions she was taking to try and ameliorate the situation, she would instead speak to the school nurse, Johnny’s relative, on occasion about it. She said her reasoning for this was because it would have been difficult to contact Mrs Shields who she knew had a busy job and she didn’t have her email and also it was difficult to find time during the busy school day to make those kinds of calls. She acknowledged she never had Johnny’s parents’ permission to discuss such matters with the school nurse, whom she described as “her first port of call” and that it would have been better, in hindsight, to have had more contact directly with them.

(23)  She explained how in term two of Year 8 a bullying survey, which were carried out at least once a term, indicated Johnny and another student X had been on the receiving end of name-calling by another student. All students involved were spoken to and to her knowledge there was no reoccurrence. She did not recall mentioning this to the school nurse. Further surveys in Year 8 flagged up concerns of Johnny’s peers about him spending a lot of time on his own outside of the classroom. She said she noted Johnny mostly seemed to prefer his own space but that she was concerned enough at his being alone at lunchtime to encourage him to use the library or ICT suite. Again she acknowledged she did not contact Mrs Shields about the surveys or her concerns regarding Johnny and she would not have been involved in student teacher meetings and did not raise it in her comments on the school report, which she said was not intended to cover those issues.

(24)  On 3 June 2015 there was an incident between Johnny and student X and Mrs Shields contacted her about it. She met with her on 4 June and Mrs Shields provided her with a list of 20 incidents of bullying of Johnny by X that had occurred over the previous five/six weeks. They then met with the Year Tutor. She said she was surprised at how many incidents Mrs Shields told her about which spanned a prolonged period which she felt would have been distressing for Johnny and was surprised Mrs Shields had not come to her sooner. She denied that Johnny had ever approached her in relation to any concerns he had, and she only apologised to him the following day for not being aware of the issues not because she had dismissed him. She clarified in her evidence that if she had appeared dismissive to him on that occasion that never would have been her intention and was not her form with pupils. She confirmed that these incidences would be considered persistent bullying and explained she followed the school’s bullying policy, met with the other student’s mother and X was sanctioned with a detention and a warning given of the consequences of a recurrence of similar behaviour. She said Johnny’s teachers were advised and asked to be vigilant for similar behaviour. She confirmed X was later suspended after making a rude gesture to Mrs Shields and said that in all her years of teaching she had not known a Year 8 to be suspended and this was indicative of how seriously they had taken the allegations of bullying.

(25)  She said she recalled Mrs Shields raising another issue with her at the end of Year 8 where X had brought in a hurling stick at a time when no games were on and that she had referred it to the Year Tutor who dealt with it and that another incident had occurred in PE which was dealt with by the Vice Principal. She was unsure if Mrs Shields had been contacted regarding the outcome of these incidents as she did not deal with them.

(26)  She explained due to her noting Johnny still was isolated in school in Year 9 an attempt was made to have Johnny buddy up with two new pupils which proved unsuccessful. She said after it was brought to her attention by Mrs Shields in Year 9 that Johnny and X had had further verbal exchanges now involving two other boys and that X and Johnny had been seated together in class, she spoke to the teachers and ensured they were not sat together and gave a talk on different forms of bullying to the form class. She also spoke to the two other boys but it appeared to be the “lowest form of bullying”. As to why X was not moved into a different class she said it was not her role to decide to move a pupil out of class and she felt moving Johnny or X into another form class would be detrimental to both of them.  She said she did not feel that X deliberately isolated Johnny from his peer group however noted the two largely kept their distance in Year 9/10 but overall felt Johnny was settling in more by the end of the year and had a few other pupils he appeared friendly with at times. She said no other instances of bullying were ever brought to her attention and she did not recall raising any of her concerns about Johnny’s isolation at school with his parents.

(27)  She described how in Year 10 Johnny continued to be isolated and she said she “felt more could be done” and discussed the issue with his Year Tutor and a member of the pastoral care team, of which she was a member, and they decided to monitor the situation. She also noted the increased use of his phone at lunchtimes however they let him continue to use it as a means of relaxation. She confirmed that again she did not relay any of this to Johnny’s parents as it was difficult to get time to do so.  She did note he had befriended a quiet Year 8 and seemed to participate and enjoy two class trips during which she said he was seen talking to and spending time with X and it was her view that their earlier issues in Year 8 and early year 9 had been resolved.

(28)  She explained her only contact with Mrs Shields in Year 10 was regarding Johnny’s unwillingness to get out of bed for school and not revising for subjects he was not intending to take for GCSE which she said was not uncommon.  After this call she said she had a catch up with Johnny who said he was just fed up with school but didn’t elaborate and during that conversation he mentioned two other boys he knew that went to a different school. She described how she commented upon this to the Vice Principal when discussing his unhappiness at school as maybe being suggestive he was considering moving. She confirmed she did not mention this to his parents but instead to the school nurse and acknowledged that she should have. She said she felt at the end of Year 10 that staying in the Abbey was the best option for Johnny and that Year 11 would be better for him with different classes and what she viewed as good pastoral care. As regards Johnny’s subsequent ASD diagnosis she said she had never had any training on it and would not have been in a position to diagnose it. It was not in her experience for teachers to raise issues of autism with parents and issues like that would usually have been picked up in primary school.

(29)  I pause here to note it was very clear from the evidence I heard at the inquest that the pastoral care afforded to Johnny in Years 8-10 was not satisfactory. While the school had in place ways of trying to meet the pastoral care needs of its students, such as the number of integrating activities in Year 8, the school counsellor, form class teachers, a pastoral care team, teachers with open door policies, bullying surveys etc there was, as is apparent in Johnny’s case, no holistic approach taken and all the attempts to ameliorate Johnny’s social isolation in school (and I will address the bullying issue later) worked in an ad hoc and silo fashion, with very few connections between or feedback on the differing attempts. Furthermore, the absence of any input by Johnny’s parents in any of the plans devised to assist Johnny’s settling into the school and subsequent social isolation was stark and the use by Mrs Lane of the school nurse as a proxy for communication with his parents entirely inappropriate. While I have no doubt Mrs Lane had wanted to assist Johnny, her complete lack of communication with his parents, unless they had contacted her regarding their concerns, meant his parents remained unaware of the continuing difficulties he faced at school and were unable to input their ideas as to how he might make friends or become more integrated. There also appears to be a lack of feedback or input from any of Johnny’s other teachers or note of any detailed consideration by the pastoral team. I also note that homework books, which were highlighted as a means of communication between parents and the teachers in the school were not used as a means of communication re pastoral issues and form teachers did not participate in parent teacher meetings so there was no way for them to have regular discussions with parents, with the exception of them contacting them directly, to raise any pastoral concerns they had. I also note Mrs Lane was clear that the input on the school report from form teachers was not intended to include information on pastoral issues and that her input was not always sought when considering Johnny at the Pastoral Team level.

(30)  Catriona O’Hare, Head of Middle School at Abbey Grammar, gave evidence to the inquest. She described how her role included overseeing and supporting the pastoral leads in both years 11 and 12 and the subsequent form teacher teams with respect to the emotional well-being of the students as well as ensuring they were working to the best of their academic ability.

(31)  She described how she first spoke to Mrs Shields on 29 August via telephone to return her call during induction week after Johnny had missed the induction meeting that morning. Mrs Shields had advised in the earlier phone call that morning that Johnny had been engaging with CAMHS since June 2017 and that he had had an ASD assessment the day before. She explained that as she had no knowledge of Johnny except a brief conversation in the June before with his then Year tutor, which would be her practice re all the new students coming into her care, she had again spoken with him (the Year Tutor) before returning the call to get further information about Johnny. She was told he was a quiet boy who had been placed in a form class with a small group of friends to support his quiet nature. She confirmed in her evidence no issues of previous bullying or that there had been concerns re Johnny’s social isolation which had been indicated to her. She spoke again with Mrs Shields on 11 September when she requested a meeting and then met with both Mr and Mrs Shields later that day. During this meeting, Johnny’s suspected mild ASD was discussed as was the large amount of time he spent online at home and their concerns regarding Johnny’s lack of social engagement and issues with confidence, especially in his academic ability in classes such as English. They also discussed his CAMHS attendance. She described the meeting as warm and friendly regarding important information sharing and said it was clear Johnny had very supportive parents. She confirmed the issue of the suicide attempts was never raised and how she would have taken an immediate different course had she known which would have enabled her to put a plan in place to ensure his wellbeing and monitor him and mitigate any risks.

(32)  With the permission of his parents, she then met with Johnny on 12 September to make him aware she knew of the ASD diagnosis and they agreed she, his Form Tutor and Year Head would know but not the other teachers and he could see them if there were any issues and sought to reassure him they were there to help. She noted he was very quiet with little eye contact. In an effort to make him feel more integrated and settled she arranged that Johnny’s form teacher would meet him in the form class when he attended each morning 30 minutes before class in order to help build a relationship and his confidence. She explained she got updates every day from his form teacher on how he was getting on.

(33)  She described how a good relationship of communication had been built up between Mrs Shields and Johnny’s Year Head regarding Johnny’s reluctance to attend school and the difficulties they were experiencing as parents with Johnny and how the Year Head and Form Tutor actively collected work for Johnny to do at home over the subsequent weeks, keeping Mrs Shields informed of same while not trying to overburden her with pressure by dealing with feedback by way of a weekly rather than daily call.

(34)  She said at the end of September she explained Johnny had returned to school and appeared to show some interest in school work again and how on October 2 the school received a call from Dr Cassidy confirming Johnny’s ASD diagnosis. She described how she emailed the various agencies and stakeholders, completing all the steps required within a day of receiving instruction as to what was needed and that Mrs Shields, like the teachers immediately responded to all requests. In her evidence it was clear that she took all steps required of her on an almost immediate basis and she sought further input from relevant colleagues such as the SEN Teacher or AAIS when these were required.

(35)  She described how she updated Mrs Shields via email on 23 October on all the steps being taken, what further information was required and also advised her of the involvement of the Education Authority’s Autism Intervention Service and referral to the Education Welfare Service regarding Johnny’s attendance, which was then at 47%, but sought to reassure her she was aware of Johnny’s current diagnosis and this was to provide pastoral support to the family. She also asked that she be able to advise Johnny’s teachers of his diagnosis to assist with the IEP, all of which were agreed by Mrs Shields and she advised the teachers accordingly.

(36)  She described how her colleague’s communication with Dr Cassidy regarding obtaining the full report indicated Johnny’s main issues were social interaction and emotional concerns rather than academic issues and that Johnny was struggling with the news about his condition and was very anxious about who would find out about his condition at school.

(37)  She described how she met then with the SEN teacher who provided her with a descriptive list of indicators of the condition of ASD. She explained she sent these to Mrs Shields who she asked to monitor Johnny’s behaviours at home over the Halloween break and feedback to agree specific targets that were manageable and attainable for Johnny. The school finished the following day for mid-term break and she was advised of Johnny’s death on her return to school on 6 November.

(38)  I find that Mrs O’Hare acted appropriately and her efforts to ensure expedition of all matters connected to Johnny’s IEP after his ASD diagnosis is to be commended. I find that she had a good and open line of communication with Johnny’s parents and kept them regularly updated. She also clearly worked to ensure that any efforts to deal with Johnny’s social isolation and confidence issues, which I note were brought to her attention by his parents, had appropriate feedback and involvement from other teachers. I find she, together with her colleagues, sensitively dealt with the ongoing attendance situation in 2017 and maintained good contact with Johnny’s parents. Indeed the level of communication and joint working between teachers, outside stakeholders and parents in organising Johnny’s IEP provides a sharp contrast to the communication levels regarding Johnny in Years 8-10.

(39)  Sean Sloan, Principal of Abbey Grammar School, gave evidence to the inquest. He explained how he joined the school a month after Johnny’s death but had interviewed relevant personnel and reviewed all the notes before making his statements. He described the school’s various interactions with Johnny as were recorded in the notes he had had. He noted Johnny was mentioned eight times at pastoral meetings in his time at the Abbey. Four occurring in the first two years, mainly settling in issues and separation from the other boy and four times in Year 11 regarding non-attendance and a possible SEN diagnosis. He was categorical that the only issues of bullying the school were aware of occurred in Year 8 and early Year 9 and no further incidents were ever brought to their attention. He emphasised the school were not aware of any attempts by Johnny to take his own life or that he had engaged in self harm nor the fact that he had had issues of technology addiction. He said this lack of knowledge made it virtually impossible for the school to provide appropriate care and resources for Johnny. He explained he had met with Johnny’s parents after his death and they had asked him to ensure that this never happened again. He highlighted the school’s approach to the IEP and the efforts made when provided with the appropriate information. He agreed that the communication with the school nurse as opposed to Johnny’s parents throughout Johnny’s early years and the lack of record keeping was inappropriate and that the lack of communication with Johnny’s parents in those years may have resulted in some way in the lack of information coming back to them. He described the many changes in policy about open communication between teachers and with parents, especially in Year 8, now in place together with the fact that Form teachers are now allotted 1.5 hours per week to deal with pastoral concerns to ensure that time is given to make calls or deal with pastoral issues together with a dedicated form class period so that pastoral issues can be dealt with. He described how there was now ASD awareness training for both teachers and pupils. He said re social isolation how the Year Tutor of Year 8 now speaks to primary schools re any incoming issues and after six weeks will get feedback from the teachers to see if there are any ongoing concerns as well as regular assessments/surveys of students, both cognitive and attitudinal. He described how there is now a Mental Health Coordinator and both bullying awareness and suicide awareness weeks are held.

(40)  Dr Quinn, Johnny’s GP gave evidence to the inquest. In his statement he described his interactions with Johnny after his suicide attempt on 2 June 2017. At the initial appointment his parents described both the incident the previous night with the nail gun and how a fortnight previous, Johnny had drunk a bottle of vodka and had taken the nail gun out, though at that time they felt this more due to the effects of alcohol. He described the second attempt as quite driven in attempting to end his life having had to search for the hidden nail cartridges. He described how he spoke with both Johnny and his parents and how Johnny had said he had no reason to be unhappy but that he hated his life, hated school and hated arguments at home and his only enjoyment was the occasional walk with his father. In the conversation about school he understood that bullying had occurred in the early years of Johnny’s schooling but had resolved and how Johnny had a very limited circle of friends and no extra-curricular interests other than the computer which had caused issues at home with overuse. He said Johnny did not mention any ongoing bullying. He described how when he asked Johnny if he would have preferred to be dead he said he would. On foot of Johnny’s presentation while at the surgery he asked for a mental health assessment that evening however was informed by CAMHS that they were a 9-5 service and could only see him the next week and that if there were problems the overnight place of safety was Daisyhill Hospital. He described this as very frustrating, not only because he had phoned within those hours requesting an assessment but also because he thought he should have been seen that day not in 5 days. He noted that adult acute mental health services had 24hr provision in contrast with child acute mental health services.

(41)  He explained that while he himself could have initiated the detention process, given the fact he knew Johnny’s parents and knew they could provide excellent care and could keep him in a place of safety, after talking with CAMHS, he felt the better option than taking a suicidal child to A&E to wait several hours was to have him go home and have CAMHS then provide input. He explained he gave them the advice that if they had further concerns over the weekend to go to A&E and that CAMHS would contact them.

(42)  I find that Dr Quinn acted appropriately.

(43)  Dr Lisheen Cassidy, Consultant Child and Adolescent Psychiatrist, gave evidence to the inquest. She had first met Johnny on 5 June after his suicide attempt of 2 June at the request of Mrs Shields and saw him a total of 16 times between then and his death. I pause here to note that Dr Cassidy’s interaction with Johnny was on foot of Mrs Shields’ direct contact with her and her agreement to see Johnny personally, as the appropriate service, the CAMHS Assessment Crisis Team (ACT) said they were short staffed and that CAMHS could not see him until the following Wednesday 7 June.

(44)  She described Johnny at their first meeting as feeling sad, lonely and frustrated with difficulty seeing a better future. His parents reported to her they began having concerns after Johnny’s move to secondary education and how he had difficulty settling in, his two friends having gone elsewhere, and was also the victim of some bullying but it was her impression while occurring in the first year it had settled and Johnny told her that he spoke to the bully now. The problems around his dislike of school had intensified in recent months and he had also been dealing with a number of loss and bereavement issues. She described his mood as fluctuating dependent on his social environment and described school as an ongoing stressor the issues there being mostly isolation and boredom.

(45)  She said his parents reported he had become more irritable and argumentative of late and a working diagnosis of a depressive episode with social anxiety was made and he was prescribed sertraline given the fact Johnny’s symptoms had been present for some time and had interfered in his day to day life. She said while there is mixed data regarding SSRIs and increased suicidal ideation and in young people it appeared to activate them a bit more at the start, there was no direct link between starting SSRIs and completed suicide. With Johnny she had no concerns that the medication was the source of his suicidal ideation and that given the level of his depression, he was better on it.

(46)  She noted over her following interactions with Johnny his presentation varied depending on what he was involved in. He was animated and talkative if talking about working with his father or computers or spending time with family but however had negative thoughts about returning to school in September his lack of friends and social isolation. She said he did not mention any ongoing bullying in any of their conversations. She felt he demonstrated an inability to problem solve or forward plan how to address these concerns and noted aspects suggestive of ASD so arranged the assessment for same. She explained she was keen for Johnny to have this assessment before his return to school and with the help of a colleague was able to facilitate it much quicker than the usual waiting period of at least six months. She described how the assessment confirmed the diagnosis and appropriate referrals were made.

(47)  She said Johnny was initially reluctant to have the school informed about his ASD diagnosis but agreed some weeks later. She was categorical that she never advised the family not to tell the school or wider family about his suicide attempts, but had rather tried to persuade Johnny who was adamant he did not want to share this information, to share the information with the school. She said she felt there was no way for her to share the confidential information without his or his parents’ consent and described it as a process and said this could be seen in her emails encouraging information sharing but confirmed she had never insisted that his parents disclose to the school about the suicide attempts.

(48)  She described how his parents reported Johnny became more irritable and even aggressive as school approached so she suggested the introduction of quetiapine in addition to the sertraline to ameliorate his agitation. While he denied ongoing active suicidal thoughts he confirmed he held it in the back of his mind so she said her interventions were geared around reducing hazards and supporting him and his family with his diagnosis and means to cope. She felt the suicide attempt on 12 September 2017 may have been triggered by Johnny’s anger at his parents for sharing the information about his ASD diagnosis and CAMHS attendance.

(49)  As regards school attendance she said he was ambivalent moving between identifying it as a means to an end and not as bad as he had anticipated and refusal to attend. She described how she made arrangements for a family counsellor to ameliorate the increasing stress levels at home. She described how she last saw Johnny and his parents on 31 October, after Johnny had stopped taking his medication leading to an increase in challenging behaviours, however he had recommenced same by the time of the appointment and was in better form looking forward to the half term break. She said it was agreed at that stage CAMHS would input in early November and Johnny was due to meet with a member of the EA Autism Support Services.

(50)  She explained that Johnny’s ASD would have made him quite rigid in his thinking and once he would get an idea into his head it would be difficult to persuade him otherwise. While she said there was limited study data on suicide by people with an ASD diagnosis, it would no doubt alter the way they thought about things and would make them less easy to predict. She was also of the view that hospitalisation was not in the best interests of Johnny given the traumatic nature of being hospitalised, which would have been further compounded by his ASD diagnosis, and the fact that she was working well with his parents and they were managing risk and dealing with the issues he had and that his risk was reducing overall. She agreed there was a difference in the provision of adult mental health services and those provided to children.

(51)  I find that Dr Cassidy acted appropriately and it was clear from her evidence that she was shocked by Johnny’s death. I find that she endeavoured to expedite his ASD assessment to facilitate his return to school and had been working well with his parents to try and manage the risk of suicide as well as trying to assist both Johnny and his family cope with his new ASD diagnosis. The fact that there was a considerable waiting period between the diagnosis and the availability of what would have in no doubt been helpful courses for both Johnny and his family, is a reflection of the funding and accompanying service provision issues sadly faced throughout the health service. I find, on the balance of probabilities, that Dr Cassidy did not say to Mr and Mrs Shields not to disclose the information regarding the suicide attempts to the school and wider family although she acknowledged in her evidence she did not tell them that to do so was necessary. Dr Cassidy’s emails are suggestive of ongoing efforts to encourage disclosure of the issues Johnny was dealing with to the school. It was appropriate that she encourage such information be shared to enable the school to take appropriate steps to protect Johnny when under their care, however I find the advice to disclose the information could have been more clear in its delivery.

(52)  Laura McMullen, CAMHS Senior Mental Health Practitioner gave evidence to the inquest. She described how she had been asked to provide an assessment after Johnny had overdosed on 12 September 2017. Johnny confirmed he did not mean to end his life although was struggling with difficulties at school which led to him experiencing fleeting TLNWL but denied any current suicidal ideation. He said the overdose was an impulsive act after an argument at home about computing as compared to his earlier attempt in June 2017. It was noted in the notes that he had been angry about the communication between his parents and the school. She noted that he presented as much more agitated when talking of school during the assessment and he confirmed instances of previous self-harm over the previous six months as a coping strategy, the most recent being the previous week. Mrs Shields described Johnny during the encounter as struggling with acceptance of his ASD diagnosis. She clarified in evidence she would have asked about whether there was any current bullying and nothing was reported. She said she assessed that Johnny did not meet the criteria for detention and could be discharged home into the care of his mother, being due to be followed up by Dr Cassidy the next day and gave them details of appropriate emergency contacts and the safety plan. As regards the request for assessment on 2 June 2017, she said that the CAMHS crisis team were only funded for hospital assessments and could only ever provide an assessment requested by a GP if they had no hospital assessments, had capacity and the request was within working hours 9-5. In this regard she said timing was “crucial”. She explained if a child presented to A&E outside 9-5 they would be admitted to a ward overnight, as was the case with Johnny and seen the next day by CAMHS.

(53)  I find that Ms McMullen acted appropriately.

(54)  Before I turn to my findings on the circumstances of Johnny’s death, I pause to say it was clear from the evidence that Johnny was a bright quiet young man with a love of all things technological who relished the opportunity to use his expertise in computers to help others. He clearly enjoyed working with his father and relished the opportunity of working with adults although it was clear he had a lot of difficulties in forming relationships with his peers. It was also clear from the evidence that Johnny came from a deeply loving protective family unit and had parents, who in an unenviable situation, tried to always do what they thought was in the best interests of their son.

(55)  I find, on the balance of probabilities, that at the time of Johnny’s death there was not ongoing persistent bullying. This is based on there being no records of any bullying allegation by Johnny, his parents or by means of communication from any of his peers through mechanisms such as the bullying survey. I also note the evidence from multiple sources that Johnny had spoken to the bully and had been in his company in the interim period. The medical records, which reflect a multitude of conversations of medical professionals with Johnny in 2017, all of whom discussed with him the issue of bullying, all reflect the understanding that while bullying had occurred in the first and second years, it was a historic rather than an ongoing issue. However, there can be no doubt that the bullying that occurred in his first two years at grammar school would have affected him even after its cessation and would have compounded his existing difficulties around forming and maintaining peer relationships.

(56)  I find that the school, when it became aware of the bullying as a result of the bullying survey, failed to raise this with Johnny’s parents and this was inappropriate and not in line with the bullying policy, which although not yet ratified, was described as being already in application in most effects in the school. As regards the persistent bullying late in Year 8, raised in the meeting of 3 June 2015, I find the school, when aware of the issues acted in a timely and appropriate manner in disciplining the student involved and meeting with Johnny’s parents. However it is stark that such persistent bullying was not picked up by teachers, despite occurring over a range of classes and over a period of five-six weeks and was only brought to the attention of the school by Mrs Shields when her son confided in her. While it must be accepted that bullying can by its very nature be pervasive and covert and can take many forms, Johnny’s case highlights the need for vigilance of other signs of bullying other than it being brought to the attention of teachers either by pupils, their peers or parents. I note that at the time of the bullying in May/June 2015 Johnny was described as displaying some of the signs of stress highlighted in the bullying policy as being indicative of bullying. Mrs Lane’s evidence highlighted the lack of communication at that time between teachers regarding bullying issues and the lack of proper recording and sharing of outcomes of actions taken.

(57)  I find that the main issues that led to school becoming an ongoing stressor for Johnny at the time of his death were both his social isolation from his peers and his boredom with the curriculum, both it appears from the evidence being perhaps a feature of his ASD. I find that the school, not being aware of the previous suicide attempts or self-harm, could not be expected to have known this and I find that in September/October 2017 to their knowledge the issues with Johnny’s non-attendance at school were his social isolation and his ASD diagnosis and their efforts to return him to school were accordingly focussed.

(58)  I find, on the balance of probabilities, that in the weeks leading up to Johnny’s death he was struggling with his return to school, which had been an ongoing stressor for a number of years, and also with his recent diagnosis of ASD, although he was becoming more accepting of same. I find that there were also ongoing stressors on the entire family regarding his use of computers and in his parents trying to impose boundaries on that use. I find that he was upset by the fact that his diagnosis of ASD and attendance at counselling was, albeit with his permission, disclosed to the school and that he found school both lonely and frustrating. I find that his suicide attempt by means of an overdose in the weeks before was impulsive rather than planned.

(59)  I find that at that time and in the weeks prior to his death he did not meet the criteria for detention under the Mental Health Order and that every attempt had been made by both his family and relevant medical staff to minimise the risk of his repeating the earlier attempt in early June 2016.

(60)  I find, on the balance of probabilities that, the balance of his mind being disturbed, Johnny, who was experiencing negative feelings regarding his return to school, and as an aspect of his condition could become fixated on an idea and have difficulties problem solving, earlier on the day of his death had gone to his father’s van and unlocked it. In the early hours of 6 November 2017 he returned to the vehicle and discharged his father’s nail gun into his head with the intention of ending his life and that the injury immediately rendered him unconscious and caused his rapid death. The post mortem records, and I find, that the cause of death is 1a penetrating brain injury.