Lessons learnt after boy, 13, dies of drug overdose

COUNCIL officials insist lessons have been learned after the death of a 13-year-old boy who ran away from a care home at Welney.Jack Windsor-Monson died of a drug overdose at his mother’s house near Great Yarmouth, after running away from the Fenland home.An independent case review commissioned by

COUNCIL officials insist lessons have been learned after the death of a 13-year-old boy who ran away from a care home at Welney.

Jack Windsor-Monson died of a drug overdose at his mother’s house near Great Yarmouth, after running away from the Fenland home.

An independent case review commissioned by Norfolk Area Child Protection Committee made more than 80 recommendations, it emerged at the boy’s inquest.

The Norwich inquest was told Jack was taken into care after the death of his father Garie Monson, 33, in a car crash in September 2002 while being pursued by police. Jack’s mother, Sarah Windsor, had a nervous breakdown and turned to alcohol.

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Jack was displaying behavioural problems and self-harming and taken into care in early 2003, spending time at a number of homes. He moved to The Cottage, run by Fenland Care at Welney, on March 20 2004 but was unhappy. He frequently absconded, often returning to his grandmother Linda Powell’s home in Gorleston.

He absconded on August 17 2004, going to Miss Powell’s house. It was agreed she would take him back to The Cottage on August 20.

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But on the evening of August 19, he went with some other youngsters to his mother’s house in Long Lane, Bradwell, knowing she would not be there.

He took a number of his mother’s prescribed pills, smoked cannabis and drank alcohol. Early in the evening he appeared to be in good spirits, though later he talked about how his life was "crap", how he missed his father and did not want to live.

At about 11.30pm Jack’s uncle, Jamie Monson, concerned for his welfare, visited the house and saw him through the window, wrapped in a duvet. He mistook a female figure for Jack’s mother and returned home, believing he was safe.

Jack was found dead of morphine poisoning in his mother’s bedroom the following morning.

Norwich coroner William Armstrong told the jury there was no evidence Jack intended to take his own life.

The jury returned a so-called narrative verdict, concluding Jack’s consumption of the drugs was a direct consequence of his disturbed state of mind.

It said his mental state was due to unresolved bereavement issues relating to his father’s death and unhappiness about being separated from family and friends, about his placements and about a care plan being discussed which could have involved his being sent to another care home outside the area.

Mr Armstrong said he was aware of the review into Jack’s case, adding: "I would like to endorse those recommendations and I’m grateful to the county council for saying they have been accepted and will be acted on."

He said: "Jack was clearly loved by his family, and particularly Linda Powell did everything she possibly could and thought was appropriate to care for him and protect him and never gave up, even though the circumstances were very difficult.

"Jack had many, many positive qualities and those things should be remembered."

He said he was encouraged Miss Windsor was making progress dealing with her alcohol problem.

After the hearing, Miss Windsor, 37, said: "This was a whitewash. I will be making a complaint to social services and asking my MP to bring it up in parliament. I will also deliver a letter to the prime minister."

She said Jack would be remembered as "a kind, loving, giving, generous, sensitive, very intelligent boy – the best son anyone could wish for."

Miss Powell, 59, said: "I’m satisfied with what the jury said. They realised in a week what social services didn’t realise in the two years they were involved with Jack."

Lisa Christensen, the council’s director of children’s services, said: "Jack was an immensely troubled boy with complex problems which included a history of self-harming, unresolved grief and substance misuse.

"This is not about a child slipping through the net. A number of agencies were involved over many years, and the independent report highlights the good work and communication between them.

"Although it was recognised that Jack's relationship with his family was extremely significant to him, it was simply not considered possible to support him safely in living with his family on a long-term basis at that time.

"Psychiatric and psychological assessments had been attempted with Jack but he would not take part in this form of assessment. Efforts were made to identify alternative forms of one-to-one support to help Jack build trusting relationships. Jack died just weeks before a final court hearing to decide his long-term future."

Fenland Care said: "Staff were shocked and deeply upset when they learned of Jack’s death. The review concluded there was nothing in the internal management to indicate that Jack’s death could have been prevented."

It said all recommendations in the review had already been implemented.

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