Inquiry blames Good Shepherd centre over Erskine Bridge deaths
A fatal accident inquiry has found that the deaths of two girls who jumped from the Erskine Bridge could have been avoided if the care home where they stayed had taken greater precautions.
Niamh Lafferty, 15, and Georgia Rowe, 14, plunged from the bridge in an apparent suicide pact in October 2009.
Both girls were residents at the Good Shepherd care centre in Renfrewshire.
A sheriff said more staff should have been on duty and the girls should not have stayed near an unalarmed exit.
Colette Bysouth, Niamh's mother, told BBC Scotland she had no indication of anything wrong on a family visit that day.
Ms Bysouth said: "She turned around, waved at me, a big happy smile. I'd said 'I'll see you soon' and off I went and that was the last time I saw Niamh alive."
The fatal accident inquiry (FAI), under Sheriff Ruth Anderson QC, took place at Paisley Sheriff Court between 15 June and 19 December last year.
The inquiry heard that Niamh and Georgia, who was from Hull, walked out of the Good Shepherd Open Unit shortly before 21:00 on Sunday 4 October 2009.
In her determination , Sheriff Anderson said their deaths were suicides.
She found that the deaths may have been avoided had "reasonable precautions been taken".
She said the girls may have lived if there had been at least four staff on duty at the Good Shepherd Open Unit on the night of the tragedy, rather than two.
Sheriff Anderson also found that Niamh and Georgia's deaths may have been avoided if they had been living on the first floor of the centre rather than in the self-contained flat on the ground floor directly opposite an unalarmed fire exit door.
In her report, Sheriff Anderson also noted several other relevant factors.
She said there was a need for a more robust approach to the issue of absconding linked to the security of the premises.
The report said management at the centre - in August, September and October 2009 - should have "given proper regard to the serious nature of the bullying" which Georgia suffered from another young resident.
Sheriff Anderson said management "should to have taken appropriate steps to ensure the removal" of either Georgia or the young person who bullied her.
The FAI highlights a failure by the authorities to hold detailed, accurate and accessible information about individual children which included the recommendations of the child's social worker or key workers.
The report said this information should hold any psychological assessment and ensure all relevant information was copied to the care establishment.
Sheriff Anderson draws attention to the need for better communication - both verbal and documentary - to ensure accurate and up-to-date information about each child is available to decision makers and those responsible for day-to-day care.
The FAI report states that there is a need for a "'stand alone" risk assessment to be carried out for each young person in the care of a residential institution with separate consideration given to the issues of "self-harm" and "suicide".
Sheriff Anderson notes that no stand alone risk assessment was ever done on either Niamh or Georgia by the care home or care authorities.
She concludes: "Had such an assessment been carried out... then management and staff charged with their health and safety would have had a readily accessible and comprehensive document... to alert them to the risks... in relation to absconding, self-harm or suicide".
Sheriff Anderson also said recommendations made by Professor Stephen Platt, from Edinburgh University, during evidence to the inquiry, should be taken on board by care authorities.
One area of concern for him was why, given the case histories of both Niamh and Georgia, no judgement as to the risk of suicide was ever reached by those at the Good Shepherd Open Unit.
His recommendations were that local authorities should commission a set of guidelines for staff working with children in care about recognising and mitigating suicide risk.
These guidelines should include a detailed protocol for handling the risks with staff being given the appropriate training.
Sheriff Anderson concluded her report by stating: "I would wish once more to express my sympathy to the families of Niamh and Georgia and to put on record how grateful I am for the way in which those who attended the inquiry conducted themselves throughout.
"They behaved with dignity and restraint throughout."
Argyll and Bute Council, which had placed Niamh Lafferty in the unit, expressed its condolences to the girls' family and friends.
It said: "Argyll and Bute Council has already taken a number of important steps to review internal processes and procedures to ensure that the process of risk assessment of accommodated children and communication about the risks they present is improved."
The council said it was "currently considering the sheriff's determination in detail" and would "strive to ensure that it has a positive and significant impact on the care of vulnerable young people in Argyll and Bute".
The Good Shepherd Centre Open Unit is now closed, but the board of managers of the centre's secure unit expressed "renewed condolences" to the girls' families.
The board said that while the open unit no longer existed, any lessons which "will be implemented in full, where they may be applicable to the secure unit, and this will undoubtedly be true also for other open and secure units across Scotland dealing with vulnerable young people".
The statement described the girls' deaths as "the saddest and most traumatic event in the history of the Good Shepherd Open Unit" and said this had been "a significant factor in the eventual closure of that unit".
It added: "No-one who worked with Georgia and Niamh was unaffected by this tragedy, which was utterly unprecedented, both in the professional lives of staff and in the history of the institution.
"The impossibility of predicting such an event emerged in the evidence, but at the same time, weaknesses in the handling of the girls' circumstances were identified, for which the board expresses its profound sorrow."
The open unit was closed in June 2010 and has now been demolished.
The Good Shepherd Secure Unit is a separate institution and was not the subject of the fatal accident inquiry's evidence gathering or deliberations.