The death of a troubled teenager who hanged himself could have been prevented by social services and mental healthcare services, a coroner ruled.
14-year-old expectant father Liam Hardy was found unconscious in a bedroom at his grandparents’ house.
The popular Sea Cadet who was a pupil Carshalton Boys Sports College hanged himself with a tie.
Liam, who lived in Lancaster Way, Worcester Park, died in hospital eight days later.
At the verdict of a five-day inquest at Croydon Coroners Court today, Coroner Selena Lynch ruled the death was most likely an accident.
Throughout the inquest the court heard Liam displayed complex behavioural and emotional problems throughout his childhood.
He would often make threats on his own life, and had once held a knife to his own throat.
Ms Lynch said: “I conclude he did not intend to die.
“He had tied ligatures around his neck before, and may not have appreciated how dangerous it is to tie things around the neck.
“Unfortunately he lost consciousness and there was no way back.”
The coroner earlier told the court about Liam’s relationship with social services.
He had grown up exposed to domestic violence, and he would often respond to difficult situations by self harming.
The teenager’s mother Janine Hardy even request Liam was taken into care while they get family affairs in order.
Ms Hardy sought help from social services in the care of Liam
Ms Lynch said: “His complex behavioural and emotional problems were not adequately or appropriately assessed by social and mental healthcare services, the risk to his life by acts of self harm was not recognised or adequately managed.
“There were failures to fully share or access information, and significant events were not dealt with in a timely fashion or at all.
“The services placed too much reliance on addressing his needs through the family therapy service who failed to acknowledge that their invention was not effective in addressing Liam’s needs.”
On Monday, June 9 we reported how Liam suffered from epilepsy as a child but grew out of the symptoms.
Earlier in the inquest the court heard he had problems at school from a young age, and his anger would manifest itself in violent outbursts towards Ms Hardy at home.
Ms Hardy sought help for her son through various sources, including the Child and Adolescent Mental Health Services (CAMHS).
But during the inquest Ms Hardy complained the services did not take them seriously.
Christine Davies, Chair of the Sutton Local Safeguarding Children’s Board, said: “We are deeply saddened by the death of Liam Hardy and we extend our sympathy and condolences to his family and friends.
“The SLSCB oversaw a rigorous and independent review of the case which highlighted issues for all the agencies supporting vulnerable children.
“The report made a series of recommendations and the agencies involved acted upon these in order to minimise the risks to vulnerable children.”
Ms Lynch recorded a narrative verdict in relation to Liam’s death.