Skip to content


13 September 2023

Inquest concludes multiple failings contributed to the death of 17-year-old Looked-After Child under care of community mental health team

5 mins

Jasmine Dunnet died on 5 March 2020, aged 17. She had been in care from the age of 12, and had a range of mental health diagnoses, which at times had led to her being placed into hospital.  

Following a deterioration in her mental state, Jasmine was found unresponsive in a toilet at Fairfield Halls in Croydon. The inquest into Jasmine’s death has found there were multiple failings by those who were charged with her care in the period leading up to her death.

The inquest into Jasmine’s death took place over a two-week period in May and June 2023. The coroner handed down his findings and conclusion after careful deliberation on 22 August 2023, finding that Jasmine died as a result of accident. She was in a state of mental crisis and did not freely intend to take her own life, and had called 999 seeking help before she died.

Jasmine had a history of mental illness, and had suffered complex trauma (including sexual exploitation as a teenager). She had multiple admissions to hospital, and had been in care since a young age. During that time in care she had lived in at least 18 placements, all over the United Kingdom, and was often moved large distances from any friends or family.

Jasmine had been outside of mainstream education since the age of 12, and was not in any steady or continuing employment at the time of her death. Neither the South West London and St. George’s Mental Health NHS Trust’s mental health team, nor the London Borough of Croydon’s social work team supported Jasmine after a court appearance on 4 March 2020 when she was in a vulnerable state.

The coroner found that a long list of failings had, or may have, contributed to her death:

  1. Failures of the Adolescent Outreach Team (AOT) (of the South-West London and St. George’s Mental Health NHS Trust):
    • Failure of the AOT’s risk assessment to provide for an adequate formulation of risk-to-self for Jasmine
    • Failure of the AOT to review and update its risk assessment following a Care Programme Approach meeting on 3 March 2020, and in particular not considering concerning incidents and behaviour in February 2020 in relation to risk that Jasmine posed to herself
    • Failure by the AOT, as an attendee at the meeting on 3 March 2020, to identify the forthcoming dates for court appearances that Jasmine had – thus not recognising and planning for supporting her at and around her court attendances on 4 and/or 5 March 2020
  2. Failures of the London Borough of Croydon:
    • An absence of maintained knowledge/fragmented response over Jasmine’s time in care
    • Inadequate accommodation provided for Jasmine generally
    • Failure to instigate and implement a plan for Jasmine’s longer-term needs
    • Not taking the role of lead agency in the care planning for Jasmine
    • Failure to identify the forthcoming dates for court appearances that Jasmine had
    • Failure to support Jasmine at court on 4 March 2020
Denise Creech, Jasmine’s sister, says:

Jasmine was supposed to be in care and well looked after, but due to the system’s failure, she died. I have lost my sister. We never got to celebrate her eighteenth birthday together. She will  never be able to see my daughter, her niece, grow up. It is so sad that one day I will have to explain what happened to her Aunty Jasmine. I have seen there are so many cases like Jasmine’s – something needs to be done about this now. 

Will Whitaker, associate at Bindmans who represents Jasmine’s family, comments:

The death of a child like Jasmine is incredibly tragic. Worse is that Jasmine was struggling so much in the years that led to her death. She was taken into care, away from family, following struggles with her mental health. She was moved away from London all around the country, up to the north of England, and lived in at least 18 different placements – she did not have anywhere stable that she was able to call ‘home’. Through that time, she was the subject of exploitation and abuse by drug dealers and others who took advantage of her. 

Jasmine’s family were desperate and looked to those who had taken charge of her care – in particular the Council and the NHS Trust – to ensure that Jasmine was getting the support and treatment she needed. Unfortunately, that support was not in place and at the most critical time when Jasmine was struggling in the midst of court proceedings brought against her, she was let down. 

This should be a wake-up call to all those involved in these sorts of cases, and to the government generally that our young people are being let down. It cannot be the case that children like Jasmine – who are vulnerable, being exploited, and asking for help – continue to be left without the support that they desperately need.

Jasmine’s family is represented by Will Whitaker of Bindmans LLP and Phillip Rule KC of No 5 Chambers.

How can we help you?

We are here to help. If you have any questions for us, please get in touch below.