The killer of South Yorkshire schoolgirl Casey Kearney had become ‘invisible’ to the council and health services that should have been helping her cope with the mental health issues which resulted from her horrendous upbringing, a report reveals.
Even though Hannah Bonser told many agencies she might harm someone, their assessments of her did not ‘identify a high risk of this occurring’.
The Independent Multi Agency Review Report, written by Professor Pat Cantrill, which was commissioned and published yesterday by NHS Doncaster, says no single agency ‘owned’ Bonser’s care and frequent movements between agencies resulted in some fragmentation of the care she received.
Bonser, aged 27, of Doncaster, was jailed for life in July after being found guilty of murdering McAuley Catholic High School pupil Casey, from Rossington, in Elmfield Park, Doncaster, on Valentine’s Day.
Prof Cantrill, a visiting professor at Sheffield Hallam University, concludes there were missed opportunities to work with Bonser more effectively.
She makes 21 recommendations for organisations involved or interested in her care. They cover a number of areas, including better monitoring, risk management, record keeping and training.
But the expert says it is important to note it was Bonser’s actions on February 14 that led to 13-year-old Casey’s death and she was convicted of murder, and not manslaughter as a result of diminished responsibility.
While under the care of the Rotherham Doncaster and South Humber NHS Foundation Trust, Bonser was seen by 16 different psychiatrists and more than 20 community workers. At that time she was a regular cannabis user.
Prof Cantrill, a former assistant chief nursing officer and senior health civil servant, says: “Nobody was identified as a lead professional to oversee and co-ordinate her care and treatment.
“Opportunities were missed to carry out thorough risk assessments.”
She said no lead professional built up a long-standing relationship with Bonser, there was no consistent approach to her treatment and there was ‘no convincing evidence’ she should have been discharged from a home treatment team the month before the murder.
She says: “The discharge plan does not demonstrate that she had been listened to.
“The potential for poor outcomes increased significantly because of a lack of early intervention. No single agency ‘owned’ her care and frequent movements between agencies resulted in a degree of fragmentation of care.
“No one person during her childhood, adolescence or adulthood established a long-standing therapeutic relationship with her, co-ordinating her care or acting as lead professional.
“This is an essential principle when managing people with borderline personality disorder. Throughout her life, it appears services failed to listen to her concerns. She was almost invisible to some services.
“What is evident is she told many agencies of her concern she was going to harm someone. There were missed opportunities to work with her more effectively. This could have changed the course of events in her life.”
Bonser herself was one of the people interviewed by Prof Cantrill, but the expert would not say what the killer had said about her actions on St Valentine’s Day.
Among Prof Cantrill’s recommendations are reviews of systems and training to address assessment issues.
Doncaster Council has also been told to review its assessment of people who want to educate their children at home.
RDaSH must review its record keeping and ‘care pathways’ between substance misuse and adult services.
Caroline Flint, Don Valley MP, said: “Bonser clearly had a troubled childhood. And while the courts found her responsible for her own actions in murdering Casey, the frequent contact Bonser had with local agencies in the last few years begs questions about the services and support provided to her.
“The responsibility is now on the various agencies to show they have fully understood what more could have been and should be done for children and young people like Hannah to help prevent future tragedies.”
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