What happened
A 12-year-old at a secondary school in north-east England was bullied online before her death. Per BBC News’s report of 11 October 2022, four months earlier she had told a nurse she was “bullied, pushed out and ignored”, and that it followed her home through lockdown, with friends blocking her out online.
She attended the emergency department with her mother on 29 May 2020, days after self-harming again, and saw the psychiatric liaison team that night. She did not meet the criteria for children’s mental health services, so it was agreed she would go to the local early help hub. No referral to the hub was made. She died on 1 October 2020.
The outcome
The inquest ran from 11 to 14 October 2022 and concluded that she took her own life. No criminal charge was brought. On 19 October the coroner sent a Regulation 28 report to the Secretary of State for Health and Social Care, reference 2022-0328.
Per the same report, in 2020 a child referred to child and adolescent mental health services would be triaged within eight weeks and treated within up to 19 weeks, against 1,595 referrals. By 2022 triage took three weeks and treatment up to 63 weeks, against 2,275. The coroner could not say whether the missing referrals would have changed the outcome.
What went wrong
The first failure is a gap, not a finding. These sources do not record what the school knew or did; the only school evidence was about what was added after she died.
The second was the plan: services named, no owner, a referral never made. A plan a family has to chase is not a plan.
The third was the handover: no safeguarding referral, no message to the trust’s own team, no communication between services.
The fourth was capacity: treatment could wait more than a year. What the school added afterwards, a mental health lead, two emotional literacy teaching assistants and deputy safeguarding leads to five, is also a list of what was missing before.
What it teaches
Bullying between pupils is a safeguarding matter when it happens off site and on a phone. Lockdown removed the informal repair schools rely on: the corridor, the apology, the friend who talks to both sides. A school that waits to be told in person hears late.
A referral is a transaction with a receipt: named service, named person, date chased, recorded outcome. “Nobody made it” stays invisible until an inquest counts it.
What a school adds after a death is an audit of what it had before.
Questions for the room
- A pupil tells a nurse or a youth worker they are bullied online. What route does that reach your school by, and who owns it?
- When you refer a pupil onward, what tells you the referral was accepted? Where would you look to prove it?
- Your pastoral team lists what it added in three years. What was there before, and what would you tell a coroner?
Evidence and limits
Both were read live on 7 November 2026: the Regulation 28 report of 19 October 2022 and BBC News’s report of 11 October 2022.
The pupil is not named, at any age, and neither is her school: the inquest was reported nationally with both, so the school would identify her. The report is cited by reference number because its published address spells her name. No member of staff is named.
The report is not a judgment, and it does not say what the school knew.
Our physical intervention and de-escalation training treats recording, referral and handover as one job.
Sources
- Courts and Tribunals Judiciary, 19 October 2022 · Regulation 28 report, ref 2022-0328 (cited by reference; the published address spells the child’s name)
- BBC News, 11 October 2022 · https://www.bbc.com/news/uk-england-tyne-63218465
Reviewed 7 November 2026.