Clinical Negligence & Catastrophic Injury Solicitors
Teen's suicide shows 'pervasive harm of sex abuse', coroner says
The death of a teenage girl four months after her twin sister took her own life demonstrates the "pervasive" harm of alleged sexual abuse, a coroner said.
Chris Gould, 17, took her own life in January 2019 while an informal patient at a mental health unit near Cambridge.
The coroner found the main causes included her mental illness, linked to alleged sexual abuse, and the suicide of her twin sister, Sam, who was 16 when she died in 2018 from a prescription drug overdose.
The inquest in Huntingdon into Chris Gould's death heard she was a "charismatic and striking young woman."
Assistant Coroner for Cambridgeshire, Nicholas Moss QC, recorded death by suicide.
He said he had heard evidence that her mental health illness was attributed to her alleged sexual abuse.
Her sister, Sam's inquest last month also heard her borderline personality disorder was "related to allegations of prolonged sexual abuse.”
Their parents, Ian Gould and Jane Cannon, told Chris's inquest the alleged abuse began in 2007.
The inquest heard that Chris, from Fulbourn near Cambridge, attempted to take her own life in May 2016.
The following month the alleged abuse was disclosed to police but, later that year, officers said there would be no further police action because the girls had not wanted to provide evidence by video interview.
Mrs Cannon said that as parents they had "never doubted, for a moment" the honesty and reliability of their daughters' abuse claims.
Mr Moss said there had been inconsistencies in Chris's dealings with health professionals, who variously diagnosed her condition as borderline personality disorder, complex post-traumatic stress disorder and mixed disorder of conduct and emotions.
He said Chris was "profoundly affected" by her sister's death. "They had gone through so much together, particularly - as reported - the alleged abuse."
Mr Moss said Cambridgeshire and Peterborough NHS Foundation Trust, which runs the Darwin Centre mental health unit in Fulbourn, "demonstrated dedication and flexibility in the arrangements" made for Chris following her sister's death.
But he raised some "shortcomings" about the night of her death, including a "momentary miscommunication" when she was let out of the unit for a cigarette and there was a failure by staff to contact railway signallers to slow nearby trains.
Chris Gould died after being hit on the railway line on 26 January 2019 but the coroner said her suicide did not mean she was failed by the professionals or her "devoted parents.”
He said: "Rather, it demonstrates the pervasive and traumatic harm caused by the alleged abuse, horribly amplified, in Chris's case, by the suicide of her sister."
In a statement, Cambridgeshire and Peterborough Safeguarding Children Partnership Board, which has commissioned a serious case review, said that "a loss of any child is devastating and our deepest condolences" were with Chris's family and friends.
The statement added: "In the past two years all agencies have strengthened guidance and collective response to children who have been the victims of sexual abuse and young people who are suffering from mental health issues."
The coroner said he would write a prevention of future deaths report that would include his concerns about the need for police to carry out "ongoing" reviews with alleged victims of crimes when trying to mount prosecutions.
A spokesman for Cambridgeshire and Peterborough NHS Foundation Trust said: “Since her death we have implemented a number of changes including the introduction of a new service for young people in mental health crisis, and we will carefully review the findings made by the coroner to embed any further learning we can."