CSCP Publishes Chloe Safeguarding Practice Review

30 October 2023

The Croydon Safeguarding Children Partnership has published a Safeguarding Practice Review concerning ‘Chloe’, who was 17 when she sadly died. She took her own life, however, the inquest verdict was ‘accident’; because when she carried out the fatal act she was in a state of mental crisis.

Chloe first came to the attention of social services in another London borough at age two, when she became subject to a child protection order due to concerns about exposure to domestic violence. She experienced significant trauma during her early years and came into statutory care just before her teenage years due to concerns about exploitation.

Over the following months and years, Chloe was placed in 18 different homes across the country, including foster homes and residential homes. She was known to self-harm and misuse drugs, and agencies often struggled to keep her safe. On four occasions, Chloe was placed in a secure unit, on four occasions, she was detained under Sc136 (Mental Health Act 1983), and on two occasions she spent a few days in a psychiatric intensive care unit.

At the time of her death, Chloe was subject to a care order and was living in semi-independent accommodation in a neighbouring borough.

The safeguarding practice review was commissioned following her death in March 2020 and was updated in 2023 to reflect the findings from the inquest.

Debbie Jones, Chair of the Croydon Safeguarding Children’s Partnership said:

“We were much saddened by Chloe’s tragic death. Our thoughts and deepest sympathies are with her family and friends.

“We know that Chloe experienced significant trauma from a very young age which impacted her throughout her life. She was supported by a wide range of agencies and professionals, many of whom showed care and compassion and did their best to meet her needs. She was frequently at crisis point and agencies struggled to keep her safe.

“The safeguarding practice review looks at what agencies can learn from Chloe’s experiences, and we fully accept the findings and the recommendations. We are working to promote a greater understanding of trauma right across our borough so that children experiencing its effects are recognised and helped at the earliest stage. “We have implemented changes to help safeguard extremely vulnerable adolescents, including those at risk of self-harm and suicide, and we will always seek to provide safe, stable, and loving homes for all children in our care.”

The full SPR is now available to read here