Serious concerns have been raised over the care given to a teenager by the mental health service prior to his death.
Benjamin Pitt, 17, was found dead in his room at Sanctuary Supported Living in Linden Road, Bognor Regis on June 7.
At an inquest in Chichester on Tuesday, a police sergeant and a senior coroner questioned if the homeless centre for young people was the right place for the teenager, who had a history of mental health problems.
The warnings came after a member of staff at the sanctuary said she had told members of the crisis team that it ‘was not the right place for Ben to be’ after he returned there around a week after trying to take his own life for a second time in three days in May.
Janice Gibaux told the inquest that staff there ‘did not have any expertise in dealing with mental health issues’, but was told by professionals that ‘it was the best place for him’.
Sergeant Paul Coles asked if the accommodation was suitable, and questioned if the care plan put in place by the home - which saw staff carry out two checks a day - was sufficient for someone who was a ‘high risk of suicide’.
Sgt Coles also questioned the home’s policy after the inquest heard that the member of staff on duty on June 7 did not attempt to enter Mr Pitt’s room for at least an hour after getting no response from her evening check, because staff were not allowed to go into a resident’s room on their own.
After phoning police, checking with other residents and trying to contact Mr Pitt via email and Facebook, she had to wait for another member of staff to attend before trying to gain access with a master key.
Senior coroner for West Sussex, Penelope Schofield adjourned the inquest until November 8, and called for a representative from the Sussex Partnership NHS Foundation Trust to attend to explain ‘why they felt the Sanctuary was a suitable place for Benjamin’.
She also called for Sanctuary’s area manager to attend and explain the home’s policy.
Mrs Schofield said: “I am not happy to continue this inquest without hearing from the mental health services in respect of their involvement with Benjamin Pitt.
“I am very concerned that we have here a 17-year-old boy with mental health difficulties who had been placed in sanctuary housing without a full and proper care plan in place.
“As we have heard, Benjamin Pitt appears to have taken his own life, though I won’t make any finding until the conclusion of this inquest.
“I require representatives of the Sussex Partnership NHS Foundation Trust to attend and explain why they felt the sanctuary was a suitable place for Benjamin to be.
“I also ask that the area manager of sanctuary housing attends to address me with regards to its policy in place which seems to prevent a member of staff from entering a resident’s room in the case of an emergency, and certainly from the evidence we have heard this was deemed to be an emergency situation.”
She added that this policy appeared to leave a ‘very real risk to other young people in similar circumstances’.
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