“Missed opportunities and failures” did not contribute to the death of a teenager three days after she was arrested, a coroner has ruled.
Kesia Leatherbarrow, 17, was found on December 3, 2013, in a garden in Hyde, Greater Manchester.
Stockport Coroner’s Court heard Kesia’s mother, Martina Brincat-Baines, described her as “a confident girl with a great sense of humour”.
But her behaviour became “more difficult, erratic and disturbing”.
She took drugs and had self-harmed.
Kesia spent time in police custody in Lancashire in October 2013 and a referral was made to Lancashire children’s services.
She moved from Chorley to her father’s home in Tameside that month and the information was passed to Tameside children’s services.
During November, Greater Manchester Police was in contact with Kesia several times, including for a report she was missing from home.
Coroner Joanne Kearsley said there was no evidence the interactions with police should have indicated Kesia was at immediate risk of self-harm, but there were missed opportunities with the way information was recorded and to refer her to other agencies.
On November 30, Kesia was arrested, the inquest heard.
A custody sergeant thought Kesia may have been intoxicated and saw signs of old self-harm marks.
No risk assessment was done, which Miss Kearsley said was a “missed opportunity” to get more information, particularly as Kesia had threatened to jump off a bridge.
Medical professionals twice saw her, but Miss Kearsley found the second assessment “fell well short of being any sort of meaningful assessment as to whether Kesia was fit enough to be detained”.
Kesia went to court on December 2, but the youth offending team worker said he was not told of any issues about self-harming, the inquest heard.
She was found hanged the following day. Miss Kearsley there was “not sufficient evidence” she intended to take her own life.
She said drugs PMA and amphetamine, found in her urine, could have affected her state of mind.
Miss Kearsley said: “There had been missed opportunities for agencies to obtain and collate information, to carry out adequate assessments of the information they held and to consider appropriate levels of support.
“Despite these failings, there is not the evidence to say on the balance of probabilities any of these matters caused or contributed to her death.”
Afterwards, Mrs Brincat-Baines said: “We are utterly devastated by the loss of our beautiful daughter Kesia.”
She was concerned the family was not told she had threatened to take her life and she hoped the failures highlighted would result in changes.
Assistant Chief Constable Garry Shewan said, after Kesia’s death, Greater Manchester Police had introduced new care processes for those in custody who they have concerns of self-harm.
An IPCC investigation found six custody sergeants had “a collective apathy towards performing the role of custody officer and providing care for detainees”, which was of “unsatisfactory performance” but not misconduct.
Unsatisfactory performance was also identified in a civilian custody detention officer and four police officers.