Charlotte Cobbald death prompts child welfare procedure review

The death of a vulnerable teenager after she injected herself with animal antibiotic has sparked a child care review in Suffolk and Essex.
Charlotte Cobbald, 17, died in August 2014 after taking the drug at her father’s farm.
At the time, she was being treated for depression, anorexia and self-harming, at the St Aubyn Centre in Colchester.
Agencies caring for her have been given three months by the local children’s safeguarding board to review procedure.
A serious case review by Suffolk Safeguarding Children’s Board detailed how Charlotte had built up animal husbandry expertise working with her father, a sheep farmer.
Procedures not uniform
When her eating disorder became known, her GP referred her to the Priory Hospital in Colchester in December 2013.

After several episodes of self harm she was admitted to St Aubyn’s because of “increasing self destructive behaviour and severe depression”.
By early summer, Charlotte was showing signs of improvement and was allowed more home visits.
However, on 29 July her mother reported her daughter was self-harming, suicidal and distressed.
Charlotte then died on 4 August, after being allowed to go on a five-hour visit to the farm, where she injected the antibiotic.
She had seen a large number of children’s health specialists, the report said, but procedures were not uniform and availability of some services had long time lags.
Also because of the large number of agencies and staff involved important details of the case, along with her parents’ anxieties and clinicians’ findings were not recorded.
Staff also needed more training in potential hazards on farms.
‘Bright and lovely’
Suffolk CCG said it had now trained GPs in safeguarding children.
A North Essex Partnership NHS Trust (NEP) spokesman expressed sorrow over the death of a “promising young woman”.
“We have already implemented the recommendations,” he said.
Jane Sayer, from Norfolk and Suffolk NHS Foundation Trust (NSFT), said: “We have acted upon these [recommendations], ensuring all our services are aware of the importance of good communication and record-keeping.”
Hilde Cobbald said: “Our 17-year-old daughter was beautiful, bright and lovely, inside and out.
“Before she became unwell, she had an inner zest for life.”