Lessons learned after teenager hangs himself at Shropshire care home

Glodie Kabela, 14, was living at The Grange Care Home, near Whitchurch.

He had been sent there to get him away from gangs in the capital, the inquest was told. Recording a narrative verdict on the death, Coroner John Ellery said he had spoken to several people, including representatives from West Mercia Police, Shropshire Council and the leader of an independent investigation into what went wrong in the lead up to Glodie's death.

He said he had accepted recommendations from them on how to learn the lessons of the case.

The teenager was originally from the Congo but had been living with his mother in London. He was brought to Shropshire by Brent Social Services but was found dead in his room at the home on April 9 last year.

Mr Ellery said: "I record that Glodie committed suicide. There were lost opportunities for a mental health assessment which individually or collectively may or may not have made a difference."

He said he did not think workers at the home would have known that Mr Kabela was going to commit suicide that night.

The inquest, at Park Inn Hotel in Telford, was told that on March 21 last year he had been told his contact visits home to London had been stopped and he had left the home and walked onto the train tracks near Whitchurch Station. Care workers said they did not feel that this was a suicide attempt, and had later returned to his normal self.

Mr Ellery said: "Lessons have been learned from a most thorough review by Brent Local Safeguarding Children Board.

"Action is being taken in training custody officers at West Mercia Police to be aware of mental health issues."